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P'

NOTES ON NUPiSING:

WHAT IT IS, AND WHAT IT IS NOT.

BT

rLOREXCE NIGHTINGALE.

LONDON :
HARRISON, 59, PALL MALL,

BOOKSELLER TO THE QUEEJ^.

[The ricjht of Translation is reserved.']

HAEBISON AND SCNS Pr.INTERS IN ORDINARY TO HER MAJESTY, ST. MARIIN's LANE.

PREFACE.

The following notes are by no means intended as a rnle of
thought by which nurses can teach themselves to nurse, still less
as a manual to teach nurses to nurse. They are meant simply to
give hints for thought to women who have personal charge of
the health of others. Every woman, or at least almost every
woman, in England has, at one time or another of her life,
charge of the personal health of somebody, whether child or
invalid, — in other words, every woman is a nurse. Every day
sanitary knowledge, or the knowledge of nursing, or in other
words, of how to put the constitution in such a state as that
it will have no disease, or that it can recover from disease,
takes a higher place. It is recognized as the knowledge which
every one ought to have — distinct from medical knowledge,
which only a profession can have.

If, then, every woman must, at some time or other of her
life, become a nurse, i.e., have charge of somebody's health,
liow immense and how valuable would be the produce of her
united experience if every woman would think how to nurse.

1 do not pretend to teach her how, I ask her to teach her-
self, and for this purpose I venture to give her some hints.

TABLE OF CONTENTS

Pages

Ventilation and Warming .... ,„. .... 8

Health of Houses .... .... .... .... 14

Petty Management .... .... .... .... 20

Noise .... .... .... .... .... .., 25

Variety .... .... .... .... ..,. 33

Taking Food .... .... .... .... .... 36

What Food? .... .... .... .... ... 39

Bed and Bedding .... ... .... .... .... 45

Light .... .... .... .... .... 47

Cleanliness op Rooms and Walls .... ... .... 49

Personal Cleanliness .... .... .... ... 52

Chattering Hopes and Advices .... .... ... 54

Observation op the Sick .... .... .... 69

Conclusion .... .... .... ... .... 71

Appendix .... .... ,... .„ .... 77

NOTES ON NUESING:

WHAT IT IS, AND WHAT IT IS NOT.

Shall we begin by taking it as a general principle — that all Disease a
disease, at some period or other of its course, is more or less a reparativs
reparative process, not necessarily accompanied with suffering : an Process,
effort of nature to remedy a process of poisoning or of decay, which has
taken place weeks, months, sometimes years beforehand, unnoticed,
the termination of the disease being then, while the antecedent
process was going on, determined ?

If we accept this as a general principle we shall be immediately
met with anecdotes and instances to prove the contrary. Just so if
we were to take, as a principle — all the climates of the earth are
meant to be made habitable for man, by the efforts of man — the
objection would be immediately raised, — Will the top of Mont Blanc
ever be made habitable ? Our answer would be, it will be many
thousands of years before we have reached the bottom of Mont Blanc
in making the earth healthy. Wait till we have reached the bottom
before we discuss the top.

In watching disease, both in private houses and in public hos- of the sulTt
pitals, the thing which strikes the experienced observer most forcibly ings of disoaic,
is this, that the symptoms or the sufferings generally considered to disease not
be inevitable and incident to the disease are very often not symptoms ^'^^'^y the
of the disease at all, but of something quite different — of the want ^^"^^*
of fresh air, or of light, or of warmth, or of quiet, or of cleanliness,
or of punctuality and care in the administration of diet, of each or
of all of these. And this quite as much in private as in hospital
nursing.

The reparative process which Nature has instituted and which we
call disease has been hindered by some want of knowledge or atten-
tion, in one or in all of these things, and pain, suffering, or interrup-
tion of the whole process sets in.

icr-

6 NOTES ON NUESIINI*.

If a patient is cold, if a patient is feverish, if a patient is faint, if
he is sick after taking food, if he has a bed-sore, it is generally the
fault not of the disease, but of the nursing.
What nursing I use the word nursing for want of a better. It has been limited to
ought to do. signify little more than the administration of medicines and the
application of poultices. It ought to signify the proper use of fresh
air, light, warmth, cleanliness, quiet, and the proper selection and
administration of diet — all at the least expense of vital power to the
patient.
Nursing the It has been said and written scores of times, that every woman

sice little makes a good nurse. I believe, on the contrary, that the very

uudersitood. elements of nursing are all but unknown.

By this I do not mean that the nurse is always to blame. Bad
sanitary, bad architectural, and bad administrative arrangements
often make it impossible to nurse. But the art of nursing ought to
include such arrangements as alone make what i understand by
nursing, possible.

The art of nursing, as now practised, seems to be expressly

constituted to unmake what God had made disease to be, viz., a

reparative process.

Nursing ousht To recur to the first objection. If we are asked, Is such or

to assist the such a disease a reparative process ? Can such an illness be unac-

reparaiive companied with suftering ? Will any care prevent such a patient

process. ^^^^ suffering this or that ? — I humbly say, I do not know. But

when you have done away with all that pain and suffering, which in

patients are the symptoms not of their disease, but of the absence of

one or all of the above-mentioned essentials to the success of

Nature's reparative processes, we shall then know what are the

symptoms of and the sufferings inseparable from the disease.

Another and the commonest exclamation which will be instantly
made is — Would you do nothing, then, in cholera, fever, &c. ? — so
deep-rooted and universal is the conviction that to give medicine is
to be doing something, or rather everything ; to give air, warmth,
cleanliness, &c., is to do nothing. The reply is, that in these and
many other similar diseases the exact value of particular remedies
and modes of treatment is by no means ascertained, while there is
universal experience as to the extreme importance of careful nursing
in determining the issue of the disease.
Nursing the H, The very elements of what constitutes good nursing are as

^^■c^^ little understood for the well as for the sick. The same laws of

health or of nursing, for they are in reality the same, obtain among
the well as among the sick. The breaking of them produces only a
less violent consequence among the former than among the latter, —
and this sometimes, not always.

It is constantly objected, — " But how can I obtain this medical

knowledge ? I am not a doctor. I must leave this to doctors."

Little under- Qh, mothers of families ! You who say this, do you know that

Ktood. Q^g j^ every seven infants in this civilized land of England perislies

before it is one year old? That, in London, two in every five die

before they are five years old ? And, in the other great cities ol

NOTES ON NURSI^^G. 7

Eagland, nearly one out of two?* "The life duration of tender
babies" (as some Saturn, turned analytical chemist, says) "is the
most delicate test" of sanitary conditions. Is all this premature
suffering and death necessary ? Or did Nature intend mothers to
be always accompanied by doctors ? Or is it better to learn the
piano-forte than to learn the laws which subserve the preservation of
offspring ?

Macaulay somewhere says, that it is extraordinary that, whereas
the laws of the motions of the heavenly bodies, far removed as
they are from us, are perfectly well understood, the laws of the
human mind, which are under our observation all day and every
day, are no better understood than they were two thousand years ago.

But how much more extraordinary is it that, whereas what we
might call the coxcombries of education — e.g., the elements of astro-
nomy— are now taught to every school-girl, neither motliers of families
of any class, nor school-mistresses of any class, nor nurses of children,
nor nurses of hospitals, are taught anything about those laws which
Grod has assigned to the relations of our bodies with the world in
which He has put them. In other words, the laws which make
these bodies, into which He has put our minds, healthy or un-
healthy organs of those minds, are all but unlearnt. Not but that
these laws — the laws of life — are in a certain measure understood,
but not even mothers think it worth their while to study them —
to study how to give their children healthy existences. They call it
medical or physiological knowledge, fit only for doctors.

Another objection.

We are constantly told, — " But the circumstances which govern
our children's healths are beyond our control. "What can we do
with winds ? There is the east wind. Most people can tell before
they get up in the morning whether the wind is in the east."

* Upon this fact the most wonderful deductions have been strung. For a Curious deduo-
long time an announcement something like -the following has been going the tions from an
round of the papers:— " More than 25,000 children die every year in London excessive
under 10 years of age; therefore we want a Children's Hospital." This spring death rate,
there was a prospectus issued, and divers other means taken to this effect: —
" There is a great want of sanitary knowledge in women ; therefore we want a
Women's Hospital." Now, both the above facts are too saclly true. But what is
the deduction 1 The causes of the enormous child mortality are petfectly well
known ; they are chiefly want of cleanliness, want of ventilation, want of white-
washing; in one word, defective household hygiene. The remedies are just as
well known ; and among them is certainly not the establishment of a Child's
Hospital. This may be a want ; just as there may be a want of hospital room for
adults. But the Registrar-General would certainly never think of giving us as
a cause for the high rate of child mortality in (say) Liverpool that there was not
sufficient hospital room for children; nor would he urge upon us, as a remedy, to
found a hospital for them.

Again, women, an 1 the best women, are wofully deficient in sanitary know-
ledge; although it is to women that we must look, first and last, for its appli-
cation, as far as household hygiene is concerned. But who would ever think of
citing the institution of a Women's Hospital as the way to cure this want 1

We have it, indeed, upon very high authority that there is some fear le<^.t
hospitals, as they have been hiih^Ho, may not have generally increased, ruther
than diminished, the rate of mortality— especially of child mortality.

8 NOTES ON NURSING.

To this one can answer witli more certainty than to the former
objections. Who is it who knows when the wind is in the east ?
Not the Highland drover, certainly, exposed to the east wind, but
the young lady who is worn out with the want of exposure to fresh
air, to sunlight, &c. Put the latter under as good sanitary circum-
stances as the former, and she too will not know when the wind is
in the east.

I. VENTILATION AND WAEMINO.

First rule of The very first canon of nursing, the first and the last thing upon

nursing, to which a nurse's attention must be fixed, the first essential to the
within as^pure P^^^^^^' without which all the rest you can do for him is as nothing,
as the air ^^^^ which I had almost said you may leave all the rest alone, is this:

without. To KEEP THE AIE HE BREATHES AS PURE AS THE EXTERNAL AIR,

WITHOUT CHILLING HIM. Yet what is SO little attended to ? Even
where it is thought of at all, the most extraordinary misconceptions
reign about it. Even in admitting air into the patient's room or
ward, few people ever think, where that air comes from. It may
come from a corridor into which other wards are ventilated, from a hall,
always unaired, always fall of the fumes of gas, dinner, of various
kinds of mustiness ; from an underground kitchen, sink, washhouse,
water-closet, or even, as I myself have had sorrowful experience, from
open sewers loaded with filth ; and with this the patient's room or
ward is aired, as it is called — poisoned, it should rather be said.
Always air from the air without, and that, too, through those
windows, through which the air comes freshest. Erom a closed
court, especially if the wind do not blow that way, air may come as
stagnant as any from a hall or corridor.

Again, a thing I have often seen both in private houses and insti-
tutions. A room remains uninhabited ; the fire place is carefully
fastened up with a board ; the windows are never opened ; probably
the shutters are kept always shut ; perhaps some kind of stores are
kept in the room ; no breath of fresh air can by possibility enter
into that room, nor any ray of sun. The air is as stagnant, musty,
and corrupt as it can by possibility be made. It is quite ripe to
breed small-pox, scarlet fever, diphtheria, or anything else you
please.*

Yet the nursery, ward, or sick room adjoining will positively be
aired (?) by having the door opened into that room. Or children will
be put into that room, without previous preparation, to sleep.

A short time ago a man walked into a back-kitchen in Queen

Why are unin- * ^^^ common idea as to uninhabited rooms is, that they may safely be left

habited rooms ^^^^ doors, windows, shutters, and chimney board, all closed— hermetically sealed

shut up 1 ^^ possible — to keep out the dust, it is said ; and that no harm will happen if the

room is but opened a short hour before the inmates are put in. I have often been

asked the question for uninhabited rooms — But when ought the windows to be

opened ] The answer is — When ought they to be shut]

YEKTILATION AlTD WAEMING. 9

square, and cut the throat of a poor consumptive creature, sitting by
the fire. The murderer did not deny the act, but simply said,
"It's all right." Of course he was mad.

But in our case, the extraordinary thing is that the victim says,
" It's all right," and that we are not mad. Yet, although we " nose"
the murderers, in the musty unaired unsunned room, the scarlet fever
which is behind the door, or the fever and hospital gangrene which
are stalking among the crowded beds of a hospital ward, we say,
"It's all right."

With a proper supply of windows, and a proper supply of fuel Without chill.
in open fire places, fresh air is comparatively easy to secure when
your patient or patients are in bed. Never be afraid of open windows
then. People don't catch cold in bed. This is a popular fallacy.
With proper bed-clothes and hot bottles, if necessary, you can
always keep a patient warm in bed, and well ventilate him at the
same time.

But a careless nurse, be her rank and education what it may,
will stop up every cranny and keep a hot-house heat when her
patient is in bed, — and, if he is able to get up, leave him compara-
tively unprotected. The time when people take cold (and there are
many ways of taking cold, besides a cold in the nose,) is when they
firstget up after the two-fold exhaustion of dressing and of having
had the skin relaxed by many hours, perhaps days, in bed, and there-
by rendered more incapable of re-action. Then the same tempera-
ture which refreshes tlie patient in bed may destroy the patient just
risen. And common sense will point out that, while purity of air is
essential, a temperature must be secured which shall not chill the
patient. Otherwise the best that can be expected will be a feverish
re-action.

To have the air within as pure as the air without, it is not
necessary, as often appears to be thought, to make it as cold.

In the afternoon again, without care, the patient whose vital
powers have then risen often finds the room as close and oppressive
as he found it cold in the morning. Yet the nurse will be
terrified, if a window is opened*.

I know an intelligent humane house surgeon who makes a Open wiudo^-a.
practice of keeping the ward windows open. The physicians and
surgeons invariably close them while going their rounds ; and the
house surgeon very properly as invariably opens them whenever the
doctors have turned their backs.

In a little book on nursing, published a short time ago, we are
told, that "with proper care it is very seldom that the windows
cannot be opened for a few minutes twice in the day to admit fresh

* It is very desirable that the windows in a sick room should be such as
that the patient shall, if he can move about, be able to open and shut them easily
himself. In fact the sick room is very seldom kept aired if this is not the case —
so very few people have any perception of what is a healthy atmosphere for the
sick. The sick man often says, "This room where I spend 22 hours out of the
24 is fresher than the other where I only spend 2. Because here I can manage
the windows myself." And it is true.

10 NOTES ON NUESIXa.

air from without." I should think not; nor twice in the hour either.

It only shows how little the subject has been considered.

What kind of Of all methods of keeping patients warm the very worst certainly

warmth jg to depend for heat on the breath and bodies of the sick. I have

desirab e. known a medical officer keep his ward windows hermetically closed,

thus exposing the sick to all the dangers of an infected atmosphere,

because he was afraid that, by admitting frei=h air, the temperature

of the ward would be too much loweied. This is a destructive

fallacy.

To attempt to keep a ward warm at the expense of making the
sick repeatedly breathe their own hot, humid, putrescing atmosphere
is a certain way to delay recovery or to destroy life.
Bedrooms Do you ever go into the bed-rooms of any persons of any class,

almost univer- whether they contain one, two, or twenty people, whether they
sally foul. i^qI^ gi(.], Qj. ^,g||^ jjt night, or before the windows are opened in
the morning, and ever find the air anything but unwholesomely
close and foul ? And why should it be so ? And of how
much importance it is that it should not be so ? During sleep,
the human body, even when in health, is far more injured by the
influence of foul air than when awake. Why can't you keep the air
all night, then, as pure as the air without in the rooms you sleep in ?
But for this, you. must have sufficient outlet for the impure air you
make yourselves to go out ; sufficient inlet for the pure air from
without to come in. Tou must have open chimneys, open windows,
or ventilators ; no close curtains round your beds ; no shutters or
curtains to your windows, none of the contrivances by which you
undermine your own health or destroy the chances of recovery of your
sick.*

An air-test of * ^^- Angus Smith's air test, if it could be made of simpler ap]>lication, would

essential he invaluable to use in every sleeping and sick room. Just as without the use of

consequence. ^ thermometer no nurse should ever put a patient into a bath, so should no nurse,
or mother, or superintendent be without the air test in any war.l, nursery, or
sleeping-room. If the main function of a nurse is to maintain the air within the
room as fresh as the air without, without lowering the temperature, then she should
always be provided with a thermometer which indicates the temperature, with
an air test which indicates the organic matter of the air. But to be used, the
latter must be made as simple a little instrument as the former, and both should
be self-registering. Th<e senses of nurses and mothers become so dulled to foul
air that they are perfectly unconscious of what an atmosphere they have let their
children, patients, or charges, sleep in. But if the tell-tale air-test were to exhibit
in the morning, both to nurses and patients and to the superior officer going round,
what the atmosphere has been during the night, I question if any greater security
could be afforded against a recurrence of the misdemeanour.

And oh ; the crowded national school ! where so many children's epidemics
have their origin, what a tale its air-test would tell ! We should have parents
saying, and saying rightly, " I will not send my child to that school, the air-test
stands at ' Horrid.' " And the dormitories of our great lioarding schools ! Scarlet
fever would be no more ascribed to contagion, but to its right cause, the air-test
standing at '' Foul,"

We should hear no longer of " Mysterious Dispensations," and of " Plague and
Pestilence," being " in God's hands," when, so far as w.- know. He has put them into
our own. The little air-test would both betray the cause d*f these "mysterious
pestilences," and call upon us to remedy it.

TLNTILATION AND WAEMI^G. 11

A careful nurse will keep a constant Avatch over her sick, When warmfh
especially weak, protracted, and collapsed cases, to guard against the °^"^^ ^'^ ™^*^^
effects of the loss of vital heat by the patient himself. In certain j^^''^'"|'.^
diseased states much less heat is produced than in health ; and there
is a constant tendency to the decline and ultimate extinction of the
vital powers by the call made upon them to sustain the heat of the
body. Cases where this occurs should be watched with the greatest
care from hour to hour, I had almost said from minute to minute.
The feet and legs should be examined by the hand from time to time,
and whenever a tendency to chilling is discovered, hot bottles, hot
bricks, or warm flannels, with some warm drink, should be made use
of until the temperature is restored. The fire should be, if necessary,
replenished. Patients are frequently lost in the latter stages of
disease from want of attention to such simple precautions. The
nurse may be trusting to the patient's diet, or to his medicine, or to
the occasional dose of stimulant which she is directed to give him,
while the patient is all the while sinking from want of a little
external warmth. Such cases happen at all times, even during the
height of summer. This fatal chill is most apt to occur towards
early morning at the period of the lowest temperature of the twenty-
four hours, and at the time when the effect of the preceding day's
diets is exhausted.

Generally speaking, you may expect that weak patients will
suffer cold much more in the morning than in the evening. The
vital powers are much lower. If they are feverish at night, with
burning hands and feet, they are almost sure to be chilly and shi-
vering in the morning. But nurses are very fond of heating the foot-
warmer at night, and of neglecting it in the morning, when they are
busy. I should reverse the matter.

All these things require common sense and care. Tet perhaps
in no one single thing is so little common sense shewn, in all ranks,
as in nursing.*

The extraordinary confusion between cold and ventilation, in Cold air not
the minds of even well educated people, illustrates this. To ventilation.
make a room cold is by no means necessarily to ventilate it. TS'or ''^^^i^^^^j'^;'^^'^ "

is it at all necessary, in order to ventilate a room, to chill it.

Yet, if a nurse finds a room close, she will let out the fire, thereby
making it closer, or she will open the door into a cold room, without
a fire, or an open window in it, by way of improving the ventilation.

* With private sick, I think, but certainly with hospital sick, the nurse should
never be satisfied as to the freshness of their atmosphere, unless she can feel the
air gently moving over her face, when still

But it is often observed that nurses who make the greatest outcry against
open windows are those who take the least pains to prevent dangerous draughts.
The door of the patients' room or ward viu.'^t sometimes stand open to allow of
persons passing in and out, or heavy things being carried in and out. The careful
nurse will keep the door sliut while she shuts the windows, and then, and not
before, set the door open, so that a patient may not be left sitting up in bed,
perhaps in a profuse perspiration, directly in the draught between the open door
and window. Neither, of course, should a patient, while being washed or in auy
way exposed, remain in the draught of an open window or door.

method of
chill.

12 KOTES ON NURSING.

The safest atmosphere of all for a patient is a good fire and an open
window, excepting in extremes of temperature. (Tet no nurse can
ever be made to understand this.) To ventilate a small room with-
out draughts of course requires more care than to ventilate a
large one.
SMght air. Another extraordinary fallacy is the dread of night air. What

air can we breathe at night but night air? The choice is between
pure night air from without and foul night air from within. Most
people prefer the latter. An unaccountable choice. What will
they say if it is proved to be true that I'ully one-half of all the disease
we suffer from is occasioned by people sleeping with their windows
shut ? An open window most nights in the year can never hurt any
one. This is not to say that light is not necessary for recovery. In
great cities, night air is often the best and purest air to be had in the
twenty-four hours. I could better understand in towns shutting the
windows during the day than during the night, for the sake of the
sick. The absence of smoke, the quiet, all tend to making night the
best time for airing the patients. One of our highest medical
authorities on Consumption and Climate has told me that the air
in London is never so good as after ten o'clock at night.
Air from the Always air your room, then, from the outside air, if possible,

outside. Windows are made to open ; doors are made to shut — a truth which

Open your seems extremely diiEcLilt of apprehension. I have seen a careful
windows, shut j^upgg airing her patient's room through the door, near to which were
your oors. ^^^ gaslights, (each of which consumes as much air as eleven men),
a kitchen, a corridor, the composition of the atmosphere in which
consisted of gas, paint, foul air, never changed, full of effluvia, includ-
ing a current of sewer air from an ill-placed sink, ascending in a con-
tinual stream by a well-staircase, and discharging themselves con-
stantly into the patient's room. The window of the said room, if
opened, was all that was desirable to air it. Every room must be
aired from without — every passage from without. But the fewer
passages there are in a hospital the better.
SmolvG. If we are to preserve the air within as pure as the air without, it

is needless to say that the chimney must not smoke. Almost all
smoky chimneys can be cured— from the bottom, not from the top.
Often it is only necessary to have an inlet for air to supply the fire,
which is feeding itself, for want of this, from its own chimney. On
the other hand, almost all chimneys can be made to smoke by a
careless nurse, who lets the fire get low and then overwhelms it with
coal; not, as we verily believe, in order to spare herself trouble, (for
very rare is unkindness to the sick), but from not thinking what
she is about.
Airing damp In laying down the principle that the first object of the nurse

things in a must be to keep the air breathed by her patient as pure as the air
patient sroom. vvithout, it must not be forgotten that everything in the room which
can give oft' efiluvia, besides the patient, evaporates itself into his
air. And it follows that there ought to be nothing in the room,
excepting him, which can give off effluvia or moisture. Out of all
damp towels, &c., which become dry in the room, the damp, of

VENTILATION AND WAEMING. 13

course, goes into the patient's air. Yet this "of course" seems as
little tliought of, as if it were an obsolete fiction. How very seldom
you see a nurse wlio acknowledges by her practice that nothing at
all ought to be aired in the patient's room, that nothing at all
ought to be cooked at the patient's fire! Indeed the arrangements
often make this rule impossible to observe.

If the nurse be a very careful one, she will, when the patient
leaves his bed, but not his* room, open the sheets wide, and throw the
bed clotlies back, in order to air his bed. And she will spread the
wet towels or flannels carefully out upon a horse, in order to dry
them. Kow either these bed-clothes and towels are not dried and
aired, or they dry and air themselves into the patient's air. And
whether the damp and effluvia do him most harm in his air or in his
bed, I leave to you to determine, for I cannot.

Even in health people cannot repeatedly breathe air in which Effluvia from
they live with impunity, on account of its becoming charged with excreta,
unwholesome matter from the lungs and skin. In disease where
everything given off from the body is highly noxious and dangerous,
not only must there be plenty of ventilation to carry off the effluvia,
but everything which the patient passes must be instantly removed
away, as being more noxious than even the emanations from the sick.

Of the fatal effects of the effluvia from the excreta it would seem
unnecessary to speak, were they not so constantly neglected. Con-
cealing the utensils behind the vallauce to the bed seems all the
precaution which is thought necessary for safety in private nursing.
Did you but think for one moment of the atmosphere under that
bed, the saturation of the under side of the mattress with the warm
evaporations, you would be startled and frightened too !

The use of any chamber utensil ivitlwut n lid* should be utterly Chamber uten-
abolished, whether among sick or well. You can easily convince si's without
yourself of the necessity of this absolute rule, by taking one with a ^^^^'

* But never, never should the possession of this indispensable lid confirm you Don't make
in the abominable practice of letting the chamber utensil remain in a patient's your sick-room
room unemptied, except once in the 24 hours, i.e., when the bed is made. Yes, into a sewer,
impossible as it may appear, I have known the best and most attentive nurses
guilty of this; aye, and have known, too, a patient afflicted with seveie diarrhoea
for ten days, and the nurse (a very good one) not know of it. because the chamber
utensil (one with a lid) was emptied only once in the 24 hours, and that by the
housemaid who came in and made the patient's bed every evening. As well
might you have a sewer under the room, or think tbat in a ^>ater closet the plug
need be pulled up but once a day. Also take care that your lid, as well as your
utensil, be always thoroughly rin-ed.

If a nurse declines to do these kinds of things for her patient, " because it is
not her business," I should say that nursing was not her calling. I have seen
surgical " sisters," women whose hands were worth to them two or three guineas
a-week, down upon their knees scouring a room or hut, because they thought it
otherwise not fit for their patients to go into. I am far from M-ishing nurses to
scour. It is a waste of power. But I do say that these v>omen had the true
nurse calling— the good of their sick first, and second only the consideration
what iiwns iheir "place" to do— and that women who wait tor the housemaid to
do this, or for the charwoman to do that, when their patients arc suLering, have
not the making of a nurse in them.

14

NOTES ON NURSING.

lid, and examining the under side of that lid. It will be found
always covered, whenever the utensil is not empty, by condensed
offensive moisture. Where does that go, when there is no lid ?

Earthenware, or if there is any wood, highly polished and
varnished wood, are the only materials fit for patients' utensils. The
very lid of the old abominable close-stool is enough to breed a pesti-
lence. It becomes saturated with offensive matter, which scouring is
only wanted to bring out- I prefer an earthenware lid as being always
cleaner. But there are various good new-fashioned arrangements.
Aboli.'h slop- A slop-pail should never be brought into a sick room. It

Piiila- should be a rule invariable, rather more important in the private

house than elsewhere, that the utensil should be carried directly to
the water-closet, emptied there, rinsed there, and brought back.
There should always be water and a cock in every water-closet for
rinsing. But even if there is not, you must carry water there to rinse
with. I have actually seen, in the private sick room, the utensils
emptied into the foot-pan, and put back unrinsed under the bed. I
can hardly say which is most abominable, whether to do this or to
rinse the utensil in the sick room. In the best hospitals it is now a
rule that no slop-pail shall ever be brought into the wards, but that
the utensils shall be carried direct to be emptied and rinsed at the
proper place. I would it were so in the private house.
Fumigations Let no one ever depend upon fumigations, " disinfectants," and

the like, for purifying the air. The offensive thing, not its smell,
must be removed. A celebrated medical lecturer began one day
" Fumigations, gentlemen, are of essential importance. They make
such an abominable smell that they compel you to open the window."
I wish all the disinfecting fluids invented made such an "abominable
smell" that they forced you to admit fresh air. That would be a
useful invention.

Health of
houses. Five
[loints essen-
tial.

Health of
tvirrianes.

There are
liouses : —

II.— HEALTH OF HOUSES. ^

five essential points in securmg the health of

1. Pure air.

2. Pure water.

3. Efficient drainage.

4. Cleanliness.

5. Light.

* The health of carriages, especially close carriages, is not of sufficient uni-
versal importance to mention here, otherwise than cursorily. Children, who are
always the most delicate test of sanitary conditions, generally cannot enter a close
carriage without being sick— and very lucky for them that it is so. A close car-
riage, with the horsehair cushions and linings always saturated with organic
matter, if to this be added the windows up, is one of the most unhealthy of human
receptacles. The idea of taking an airing in it is something preposterous. Dr.
Angus Smith has shown that a crowded railway carriage, wliich goes at the rate
of 30 miles an hour, is as unwholesome as the strong smell of a sewer, or as a
Lack yard in one of the most unhealthy couits oti" one of the most unhealthy
streets in Manchester.

HEALTH or HOUSES. 15

Without these, no house can be healthy. And it will be unhealthy
just in proportion as they are deficient.

1. To have pure air, your house must be so constructed as that the Pure air.
outer atmosphere shall tind its way with ease to every corner of it.
House architects hardly ever consider this. The object in building a
house is to obtain the largest interest for the money, not to save
doctors' bills to the tenants. But, if tenants should ever become so

wise as to refuse to occupy unhealthily constructed houses, and if
Insurance Companies should ever come to understand their interest
so thoroughly as to pay a Sanitary Surveyor to look after the houses
where their clients live, speculative architects would speedily be
brought to their senses. As it is, they build what pays best. And
there are always people foolish enough to take the houses they build.
And if in the course of time the families die off, as is so often the
case, nobody ever thinks of blaming any but Providence* for the
result. IJl-informed medical men aid in sustaining the delusion, by
laying the blame on " current contagions." Badly constructed houses
do for the healthy what badly constructed hospitals do for the sick.
Once insure that the air in a house is stagnant, and sickness is
certain to follow.

2. Pure water is more generally introduced into houses than it Pure water,
used to be, thanks to the exertions of the sanitary reformers.
Within the last few years, a large part of London was in the daily

habit of using water polluted by the drainage of its sewers and
water closets. This has happily been remedied. But, in many
parts of the country, well water of a very impure kind is used for
iomestic purposes. And when epidemic disease shows itself, persons
using such water are almost sure to suffer.

3. It would be curious to ascertain by inspection, how many Drainage.
houses in London are really well drained. Many people would say,

surely all or most of them. But many people have no idea in what
good drainage consists. They think that a sewer in the street, and
a pipe leading to it from the house is good drainage. All the while
the sewer may be nothing but a laboratory from which epidemic
disease and ill health is being distilled into the house. No liouso
with any untrapped drain pipe communicating immediately with a
sewer, whether it be from water closet, sink, or gully-grate, can ever
be healthy. An untrapped sink may at any time spread fever
or pyaemia among the inmates of a palace.

The ordinary oblong sink is an abomination. That great surface Sinks,
of stone, which is always left wet, is always exhaling into the air. I
have known whole houses and hospitals smell of the sink. 1 have
met just as strong a stream of sewer air coming up the back stair-
case of a grand London house from the sink, as 1 have ever met at

• God lays down certain physical laws. Upon His carrying out such Iaw8
depends our responsibility (ihat much abused word), ior how could we have any
responsibility for actions, the rcsjults of which we could not foresee— which would
be the case if the carrying out of His laws were not certain. Yet we seem to be
continually expecting that He will work a miracle- i. e. break His own laws
expressly to i clieve us of responsibility.

16 NOTES ON NUESING.

Scutari ; and I have seen the rooms in that house all ventilated by
the open doors, and the passages all wwventilated by the closed
windows, in order that as much of the sewer air as possible might
be conducted into and retained in the bed-rooms. It is wonderful.

Another great evil in house construction is carrying drains
underneath the house. Such drains are never safe. All house
drains should begin and end outside the walls, INIany people will
readily admit, as a theory, the importance of these things. But how
few are there who can intelligently trace disease in their households
to such causes ! Is it not a fact, that when scarlet fever, measles, or
small-pox appear among the children, the very first thought which
occurs is, "where" the children can have "caught" the disease?
And the parents immediately run over in their minds all the families
with whom they may have been. They never think of looking at
home for the source of the mischief If a neighbour's child is seized
with small pox, the first question which occurs is whether it had
been vaccinated. No one would undervalue vaccination ; but it
becomes of doubtful benefit to society when it leads people to look
abroad for the source of evils which exist at home.
Cleaulinefos. 4. ^A'ithout cleanliness, within and without your house, ventila-
tion is comparatively useless. In certain foul districts of London,
poor people used to object to open their windows and doors because
of the foul smells that came in. Eich people like to have their
stables and dunghill near their houses. But does it ever occur to
them that with many arrangements of this kind it would be safer
to keep the windows shut than open ? You cannot have the air
of the house pure with dung heaps under the windows. These are
common all over London. And yet people are surprised that their
children, brought up in large " well-aired" nurseries and bed-rooms
suffer from children's epidemics. If they studied Nature's laws in
the matter of children's health, they would not be so surprised.

There are other ways of having filth inside a house besides having
dirt in heaps. Old papered walls of years' standing, dirty carpets,
unclean sed furniture, are just as ready sources of impurity to the air
as if there were a dung-heap in the basement. People are so unac-
customed from education and habits to consider how to make a home
healthy, that they either never think of it at all, and take every
disease as a matter of course, to be " resigned to" when it comes
" as from the hand of Providence ;" or if they ever entertain the
idea of preserving the health of their household as a duty, they are
very apt to commit all kinds of " neghgences and ignorances" in
performing it.
Light. 5. A dark house is always an unhealthy house, always an ill- aired

house, always a dirty house. Want of light stops growth, and pro-
motes scrofula, rickets, &.C., among the children.

People lose their health in a dark house, and if they get ill they
cannot get well again in it. More will be said about this farther on.
Three common Three out of many " negligences and ignorances" in managing the
errors^in^ healtli of houses generally, I will here mention as specimens — 1. That
health ot^ ^ ^^^ female head in charge of any building does not think it necessary to
houses.

HEALTH OF HOUSES. 17

visit every hole and corner of it every day. How can she expect those
who are under her to be more careful to maintain her house in a
healthy condition than she who is in charge of it ? — 2. That it is not
considered essential to air, to sun, and to clean rooms while unin-
habited ; which is simply ignoring the first elementary notion of
sanitary things, and laying the ground ready for all kinds of
diseases. — 3. That the window, and one window, is considered
enough to air a room. Have you never observed that any room
without a fire-place is always close? And, if you have a fire-place,
would you cram it up not only with a chimney-board, but perhaps
with a great wisp of brown paper, in the throat of the chimney —
to prevent the soot from coming down, you say ? If your chimney
is foul, sweep it ; but don't expect that you can ever air a room with
only one aperture ; don't suppose that to shut up a room is the way
to keep it clean. It is the best way to foul the room and all that is
in it. Don't imagine that if you, who are in charge, don't look to
all these things yourself, those under you will be more careful than
you are. It appears as if the part of a mistress now is to complain
of her servants, and to accept their excuses — not to show them how
there need be neither complaints made nor excuses.

But again, to look to all these things yourself does not mean to Headin-harge
do them yourself "I always open the windows," the head in jj"^*'. ^®^*^
charge often says. If you do ifc, it is by so much the better, cer- piene, not do
tainly, than if it were not done at all. But can you not insure that it herself,
it is done when not done by yourself ? Can you insure that it io
not undone when your back is turned ? This is what being " in
charge " means. And a very important meaning it is, too. The
former only implies that just what you can do with your own hands
is done. The latter that what ought to be done is always done.

And now, you think these things trifles, or at least exaggerated. I^oob God
But what you " think " or what I " think " matters little. Let us ^^\^^- ^^ ^^^<^^^
see what God thinks of them. God always justifies His ways. t^'p.^^J^''^
While we are thinking, He has been teaching. I have known
cases of hospital pyaemia quite as severe in handsome private houses
as in any of the worst hospitals, and from the same cause, viz., foul air.
Yet nobody learnt the lesson. Nobody learnt anijtldng at all from
it. They went on thinhing — thinking that the sufferer had scratched
his thumb, or that it was singular that "all the servants" had
"whitlows," or that something was "much about this year; there
is always sickness in our house." This is a favourite mode of
thought — leading not to inquire what is the uniform cause of these
general " whitlows," but to stifle all inquiry. In wiiat sense is
" sickness" being " always there," a justification of its being " there"
at all ?

1 will tell you what was the cause of this hospital pyaemia being How does Tie
in that large private house. It was that the sewer air from an ill- carry oui His
placed sink was carefully conducted into all the rooms by sedulously 1-^'^^
opening all the doors, and closing all the passage windows. It was
tkat the slops were emptied into the foot pans ; — it was that the
utensils were never properly rinsed ; — it was that the chamber

0

18

NOTES ON NURSING.

crockery was rinsed with dirty water; — it was that the beds were
never properly shaken, aired, picked to pieces, or changed. It was
that the carpets and curtains were always musty ; — it was that the
furniture was always dusty ; it was that the papered walls were satu-
rated with dirt ; — it was that the floors were never cleaned ; — it was
that the uninhabited rooms were never sunned, or cleaned, or aired ;
— it was that the cupboards were always reservoirs of foul air; — it
was that the windows were always tight shut up at night ; — it was
that no window was ever systematically opened, even in the day, or
that the right window was not opened. A person gasping for air
might open a window for himself. But the servants were not taught
to open the windo^^■s, to shut the doors ; or they opened the windows
upon a dank well between high walls, not upon the airier court ;
or they opened the room doors into the unaired halls and passages,
by way of airing the rooms. Now all this is not fancy, but fact.
JIowdoesHe In that handsome house I have known in one summer three
teach His cases of hospital pyaemia, one of phlebitis, two of consumptive
laws? cough : all the immediate products of foul air. AVhen, in temperate

climates, a house is more unhealthy in summer than in winter, it
is a certain sign of something wrong. Yet nobody learns the lesson.
Yes, God always justifies His ways. He is teaching while you are
not learning. This poor body loses his finger, that one loses his life.
And all from the most easily preventible causes.*

The houses of the grandmothers and great grandmothers of this
generation, at least the country houses, with front door and back
door always standing open, winter and summer, and a thorough
draught always blowing through — with all the scrubbing, and clean-
ing, and polishing, and scouring which used to go on, the grand-
mothers, and still more the great grandmothers, always out of doors
and never with a bonnet on except to go to church, these things
entirely account for the fact so often seen of a great grandmother,
who was a tower of physical vigour descending into a grandmother
perhaps a little less vigorous but still sound as a bell and healthy
to tho core, into a mother languid and confined to her carriage and
house, and lastly into a daughter sickly and confined to her bed.
Tor, remember, even with a general decrease of mortality you may
often find a race thus degenerating and still oftener a family. You
may see poor little feeble washed-out rags, children of a noble stock,
suffering morally and physicall), throughout their useless, degenerate

^ervautb' * I must say a word about servants' bed-rooms. From the way they are built,

''ojixia. but oftener from the way they are kept, and from no intelligent inspection what-

ever being- exerci^sed over them, they are almost invariably dens of foul air, and the
"servants' health" suffeis in an "unaccountable" (1) way, even in the country.
For I am by no means speaking only of London houses, where too often servants
are put to live under the ground and over the roof. But in a country ''mansion,"
which was really a "mansion," (not after the fashion of advertisements), I have
known three maids who slept in the same room ill of scarlet fever. " How^ catching
it is," was of course the remark. One look at the room, one smell of the room, was
quite enough. It was no longer " unaccountable." The room w-as not a small
one ; it was up stars, and it had two large windows— but nearly every one of the
neglects enumerated above was there.

Physical dege^
Deration in
families. Its
causes.

HEALTH OF HOUSES. 19

lives, and yet people who are going to marry and to bring more such
into the world, will consult nothing but their own convenience as to
where they are to live, or how they are to live.

"With regard to the health of houses where there is a sick person, Don't make
it often happens that the sick room is made a ventilating shaft for the your sick-
rest of the house. Tor while the house is kept as close, unaired, ^^^^ ii^^o a
and dirty as usual, the window of the sick room is kept a little open ^f^f/'^^'^^f
always, and the door occasionally. Now, there are certain sacrifices ^yi^yie house
which a house with one sick person in it does make to that sick
person: it ties up its knocker; it lays straw before it in the street.
Why can't it keep itself thoroughly clean and unusually well aired,
in deference to the sick person ?

We must not forget what, in ordinary language, is called Infection.
" Infection ;" * — a thing of whi<}h people are generally so afraid that
they frequently follow the very practice in regard to it which they
ought to avoid. Nothing used to be considered so infectious or
contagious as small pox; and people not very long ago used to cover
up patients with heavy bed clothes, while they kept up large fires
and shut the windows. Small pox, of course, under this regime, is
very " infectious." People are somewhat wiser now in their manage-
ment of this disease. They have ventured to cover the patients
lightly and to keep the windows open; and we hear much less of
the " infection " of small pox than we used to do. But do people
in our days act with more wisdom on the subject of "infection" iu
fevers — scarlet fever, measles, &c. — than their forefathers did with
small pox ? Does not the popular idea of "infection " involve that
people should take greater care of themselves than of the patient ?
that, for instance, it is safer not to be too much with the patient,
not to attend too much to his wants ? Perhaps the best illustration
of the utter absurdity of this view of duty in attending on " infectious"
diseases is aff'orded by what was very recently the practice, if it is

* Is it not living in a continual mistake to look upon diseases, as we do now, Diseases are
as separate entities, wliich must exist, like cats and dogs ] instead of looking upon not individuals
them as conditions, like a dirty and a clean condition, and just as much under arranged in
our own control ; or rather as the reactions of kindly nature, against the condi- classes, like
ions in which we have placed ourselves. cats and doj,s,

I was brought up, both by scientific men and ignorant women, distinctly to but conditions
believe that small-pox, for instance, was a thing of which there was once a first grovvin<r out of
specimen in the world, which went on propagating itself, in a perpetual chain ot one another.
descent, just as much as that there was a first dog, (or a first pair of dogs), and
that small-pox would not begin itself any more than a new dog would begin
without there having been a parent dog.

Since then 1 have seen with my eyes and smelt with my nose small-pox grow-
ing up in first specimens, either in close rooms or in overcrowded wards, where
it could not by any possibility have been " caught," but must have begun.

Nay, more, I have seen diseases begin, grow up, and pass into one another.
Now, dogs do not pass into cats.

I have seen, for mstance, with a little overcrowding, continued fever grow up ;
»nd with a little more, typhoid fever; and with a little more, typhus, and all in
ihc same ward or hut.

Would it not be far better, truer, and more practical, if we looked upon
diiicase in this light 1

For diseases, as all experience shows, are adjectives, not noun substantives.

c 2

20

KOTES ON NUBSING.

Wlij must
children have
measles, &c. 1

not so even now, in some of the European lazarets — in which the
plague-patient used to be condemned to the horrors of filth, over-
crowding, and want of ventilation, while the medical attendant was
ordered to examine the patient's tongue through an opera-glass and
to toss him a lancet to open his abscesses with !

True nursing ignores infection, except to prevent it. Cleanliness
and fresh air from open windows, with unremitting attention to the
patient, are the only defence a true nurse either asks or needs.

"Wise and humane management of the patient is the best safe-
guard against infection.

There are not a few popular opinions, in regard to which it is
useful at times to ask a question or two. For example, it is com-
monly thought that children must have what are commonly called
" children's epidemics," " current contagions," &c., in other words,
that they are born to have measles, hooping-cough, perhaps even
scarlet fever, just as tliey are born to cut their teeth, if they live.

Now, do tell us, M'hy must a cliild have measles ?

Oh because, you say, we cannot keep it from infection — other
children have measles — and it must take them — and it is safer that
it should.

But why must other children have measles? And if they have,
why must yours have them too ?

If you believed in and observed the laws for preserving the health
of houses which inculcate cleanliness, ventilation, white-washing, and
other means, and which, by the way, are laws, as implicitly as you
believe in the popular opinion, for it is nothing more than an opinion,
that your child must have children's epidemics, don't you think that
vpon the whole your child would be more likely to escape altogether?

III. PETTI MANAGEMENT.

I'olty
aianasrement

All the results of good nursing, as detailed in these notes, may
be spoiled or utterly negatived by one defect, viz. : in petty manage-
ment, or, in other words, by not knowing how to manage that what
you do when you are there, shall be done when you are not there.
The most devoted friend or nurse cannot be always there. Nor is it
desirable that she should. And she may give up her health, all her
other duties, and yet, for want of a little management, be not one-half
so efiicient as another who is not one-half so dcAaited, but who has
this art of multiplying herself — that is to say, the patient of the
first will not really be so well cared for, as the patient of the second.

It is as impossible in a book to teach a person in charge of sick
how to riiaiiage, as it is to teach her how to nurse. Circumstances
must vary with each different case. But it is possible to press upon
her to think for herself: Now what does happen during my absence?
X am obliged to be away on Tuesday. But fresh air, or punctuality
is not less important to mv patient on Tuesday than it was on

PETTY MANAGEMENT. 2i

Monday. Or : At 10 p.m. I am never with my patient ; but quiet is
of no less consequence to him at 10 than it was at 5 minutes to 10.

Curious as it may seem, this very obvious consideration occurs
comparatively to few, or, if it does occur, it is only to cause the
devoted friend or nurse to be absent fewer hours or fewer minutes
from her patient — not to arrange so as that no minute and no hour
shall be for her patient without the essentials of her nursing.

A very few instances will be sufficient, not as precepts, but as Illustrations of
illustrations. ^^'^ '^•^^^ ^^ '^•

A strange washerwoman, coming late at night for the "things," Strangers
will burst in by mistake to the patient's sick-room, after he has coming into
fallen into his first doze, giving him a shock, the effects of which are ^^^"^ ^'^^ ''^°"'-
irremediable, though he himself laughs at the cause, and probably
never even mentions it. The nurse who is, and is quite right to be,
at her supper, has not provided that the washerwoman shall not lose
her way and go into the wrong room.

The patient's room may always have the window open. But the S'ck room
passage outside the patient's room, though provided with several large amngtie
r. o i T^^ ^ -i • i. J i. J whole hou.-e.

windows, may never have one open. Because it is not understood

that the charge of the sick-room extends to the charge of the passage.
And thus, as often happens, the nurse makes it her business to turn
the patient's room into a ventilating shaft for the foul air of the
whole house.

An uninhabited room, a newly painted room,* an uncleaned Uninliai>it<^(l
closet or cupboard, may often become a reservoir of foul air for the room jouhug
whole house, because the person in charge never thinks of arranging ^^^^^
that these places shall be always aired, always cleaned; she merely
opens the window herself " when she goes in." -n r • - - i

An agitating letter or message may be delivered, or an important ^^^^JgJ|^.J,^.^^!
letter or message not delivered ; a visitor whom it was of consequence ^^ igi-ters and
to see, may be refused, or one whom it was of still more consequence messages.
not to see may be admitted— because the person in charge has never
asked herself this question, AVhat is done when I am not there ? t

At all events, one may safely say, a nurse cannot be with the

* That excellent paper, the Builder, mentions the lingering of the smell of Lingering
paint for a month about a house as a proof of want of ventilation. Certainly— smell of paint
and, where there are ample windows to open, and these are never opened to get a want ot curt,
rid of the smell of paint, it is a proof of want of management in using the means
of ventilation. Of course the smell will then remain for months. Why should it go ']

+ Why should you let your patient ever be surprised, except by thieves 1 I do why let your
not know. In England, people do not come down the chimney, or through the patient ever
window, unless they are thieves. They come in by the door, and somebody must {^^ surprised .■'
open the door to them. The " somebody" charged with opening the door is one of
two, three, or at most four persons. Why cannot these at most, four persons be
pui in charge as to what is to be done when there is a ring at the door bell 1

The sentry at a post is changed much oftener than any servant at a private
house or institution can possibly be. But what should we think of such an excuse
as this : that the enemy had entered such a post because A and not B had been
on guard] Yet I have constantly heard such an excuse made in the private
house or institution and accepted: viz., that such a person had been "let in" or
■/,ot " let in," and such a parcel had been wrongly delivered or lost because A
and not B had opened the door !

22

NOTES ON NUESINU.

Partial mea-
sures such as
" lieing always
In the way"
yourself, in-
crease instead
of saving thj
patient's
anxiety. Be-
cause they
must be only
partial.

A'liat is the
cause of half
the accidents
which
happen ?

patient, open the door, eat her meals, take a message, all at one and
the same time. Nevertheless the person in charge never seems to
look the impossibility in the face.

Add to this that the aitempting this impossibility does more to
increase the poor Patient's hurry and nervousness than anything else.

It is never thought that the patient remembers these things it*
you do not. He has not only to think whether the visit or letter
may arrive, but whether you will be in the way at the particular day
and hour when it may arrive. So that your partial measures for
"being in the way" yourself, only increase the necessity for his
thougjit. "Whereas, if you could but arrange that the thing should
always be done whether you are there or not, he need never think
at all about it.

For the above reasons, whatever a patient can do for himself, it
is better, i.e. less anxiety, for him to do for himself, unless the
person in charge has the spirit of management.

It is evidently much less exertion for a patient to answer a letter
for himself by return of post, than to have four conversations, wait
five days, have six anxieties before it is off his mind, before the
person who is to answer it has done so.

Apprehension, uncertainty, waiting, expectation, fear of surprise,
do a patient more harm than any exertion. Remember, he is flice
to face with his enemy all the time, internally wrestling with him,
having long imaginary conversations with him. Ton are thinking of
something else. " Eid him of his adversary quickly," is a first rule
with the sick.*

For the same reasons, always tell a patient and tell him before-
hand when you are going out and when you will be back, whether it
is for a day, an hour, or ten minutes. You fancy perhaps that it is
better for him if he does not find out your going at all, better for
him if you do not make yourself " of too much importance " to him ;
or else you cannot bear to give him the pain or the anxiety of the
temporary separation.

No such thing. You ought to go, we will suppose. Health or duty
requires it. Then say so to the patient openly. If you go without his
knowing it, and he finds it out, he never will feel secure again that
the things which depend upon you will be done when you are away,
and in nine cases out often he will be right. If you go out without
telling him when you will be back, he can take no measures nor
precautions as to the things which concern you both, or which you
do for him.

If you look into the reports of trials or accidents, and especially
of suicides, or into the medical history of fatal cases, it is almost
incredible how often the whole thing turns upon something w^hich

* There are many physical operations where ccBteris paribus the danger is in
a direct ratio to the time the operation lasts; and coeteri,^ paribus the operators
success will be in direct ratio to his quickness. Now there are many mental ope-
rations where exactly the same rule holds good with the sick ; cceteris jyai'ibus
their capability of bearing such operations depends directly on the quickness,
without hurry, with which they can be got through.

PETTY MANAGEMENT. 23

has happened because "he," or still oftener "she," "was not there."
But it is still more incredible how often, how almost always this is
accepted as a sufficient reason, a justification ; why, the very fact of
the thing having happened is the proof of its not being a justification.
The person in charge was quite right not to be " there,''' he was called
away for quite sufficient reason, or he was away for a daily recurring
and unavoidable cause : yet no provision was made to supply his
absence. The fault was not in his "being away," but in there being-
no management to supplement his " being away." When the sun is
under a total eclipse or during his nightly absence, we light candles.
But it would seem as if it did not occur to us that we must also
supplement the person in charge of sick or of children, whether
under an occasional eclipse or during a regular absence.

In institutions where many lives would be lost and the eifect
of such want of management would be terrible and patent, there is
less of it than in the private house.*

Petty manaffo-

* So true is this that I could mention two cases of women of very high posi- ment bettei
tion, both of whom died in the same way of the consequences of a surgical understood ia
operation. And in both cases, 1 was told by the highest authority that the fatal institutions
result would not have happened in a London hospital. than in private

But, as far as regards the art of petty management in hospitals, all the mill- houses,
tary hospitals I know must be excluded. Upon my own experience I stand, and ,

I solemnly declare that I have seen or known of fatal accidents, such as suicides V mstitu-
in delirium tieinens, bleedings to death, dying patients dragged out of bed by tions are the
drunken Medical Staff Corps men, and many other things less patent and striking, exception .
which would not have happened in London civil hospitals nursed by women. The
medical officers should be absolved from all blame in these accidents. How can
a medical officer mount guard all day and all night over a patient (say) in deli-
rium tremens ? The frtult lies in there being no organized system of attendance.
Were a trustworthy man in charge of each ward, or set of wards, not as office
clerk, but as head nurse, (and head nurse the be.st hospital Serjeant, or ward mas-
ter, is not now and cannot be, from default of the proper regulations), the thing
would not, in all probability, have happened. But were a trustworthy tvornan in
charge of the ward, or set of wards, the thing would not, in all certainty, have
happened. In other words, it does not happen where a trustworthy woman is
really in charge. And, in these remarks, 1 by no means refer only to exceptional
times of great emergency in war hospitals, but also, and quite as much, to the
ordinary run of military hospitals at home, in time of peace ; or to a time in war
when our army was actually more healthy than at home in peace, and the pres-
sure on our hospitals consequently much less.

It is often said that, in regimental hospitals, patients ought to "nurse each Nursing in
other,'' because the number of sick altogether being, say, but thirty, and out Regimental
of these one only perhaps being seriously' ill, and the other twenty-nine having Hospitals,
little the matter with them, and nothing to do, they should be set to nurse the
one ; also, that soldiers are so trained to obey, that they will be the most
obedient, and therefore the best of nurses, add to which they are always kind to
their comrades.

Now, have those who say this considered that, in ord'^r to obey, you must
know /low to obey, and that these soldiers certainly do not know how to obey in
nursing. I have seen these "kind" fellows land how kind they are no one
knows so well as myself) move a comrade so that, m one case at least, the man
died in the act. I have seen the comrades' " kindness " produce abundance of
spirits, to be drunk in secret. Let no one understand by this that female nurses
ought to, or could be introduced in reginientnl hospitals. It would be most
undesirable, even were it not impossible. But the head nurseship of a hospital

l»e " in
cluir

24 KOTES ON NURSING.

But in both, let whoever is in charge keep this simple question m
her head {not, how can I always do this right thing myself, but) how
can I provide for this right thing to be always done ?

Then, when anything wrong has actually happened in consequence
of her absence, which absence we will suppose to have been quite
right, let her question still be {not, how can I provide against any
more of such absences ? which is neither possible nor desirable, but)
how can I provide against any thing wrong arising out of my
absence ?
What it is to How few men, or even women, understand, either in great or in

little things, what it is the being " in charge " — I mean, know how to
carry out a " charge." From the most colossal calamities, down to the
most trifling accidents, results are often traced (or rather not traced)
to such want of some one " in charge " or of his knowing how to be
"in charge." A short time ago the bursting of a funnel-casing on
board the finest and strongest ship that ever was built, on her trial
trip, destroyed several lives and put several hundreds in jeopardy —
not from any undetected flaw in her new and untried works — but
from a tap being closed which ought not to have been closed — from
what every child knows would make its mother's tea-kettle burst.
And this simply because no one seemed to know what it is to be " in
charge," or ivlio was in charge. Nay more, the jury at the inquest
actually altogether ignored the same, and apparently considered the
tap "ill charge," for they gave as a verdict "accidental death."

This is the meaning of the word, on a large scale. On a much
smaller scale, it happened, a short time ago, that an insane person
burnt herself slowly ana mtentionaliy to death, while in her doctor's
charge and almost m her nurse's presence. Yet neither was consi-
dered "at all to blame." The very fact of the accident happening
proves its own case. There is nothing more to be said. Either
they did not know their business or they did not know how to
perform it.

To be "in charge " is certainly not only to carry out the proper
measures yourself but to see that every one else does so too ; to see
that no one either wilfully or ignorantly thwarts or prevents such
measures. It is neither to do everything yourself nor to appoint a
number of people to each duty, but to ensure that each does that
duty to which he is appointed. This is the meaning which must be
attached to the word by (above all) those " in charge " of sick, whether
of numbers or of individuals, (and indeed I think it is with individual
sick that it is least understood. One sick person is often waited
on by four M'ith less precision, and is really less cared for than ten
who are waited on by one ; or at least than 40 who are waited on
by 4; and all for want of this one person " in charge").

Serjeant is the more essential, the more important, the more inexperienced the
nurses. Undoubtedly, a London hospital " sister " does sometimes set relays of
patients to watch a critical case ; but, undoubtedly also, always under her own
superintendence ; and she is called to whenever there is something to be done,
and she knows how to do it. The patients are not left to do it of their own
xmassisted genius, however " kinfl " and willing they may be.

NOISE. 25

It is often said that there are few good servants now : I say there
are few good mistresses now. As the jury seems to have thought
the tap was in charge of the ship's safety, so mistresses now seem
to think the house is in charge of itself. They neither know^ how to
give orders, nor how to teach their servants to obey orders — /. e. to
obey intelligently, which is the real meaning of all discipline.

Again, people who are in charge often seem to have a pride in feel-
ing that they will be " missed," that no one can understand or carry
on their arrangements, their system, books, accounts, &c., but them-
selves. It seems to me that the pride is rather in carrying on a
system, in keeping stores, closets, books, accounts, &c., so that any
body can understand and carry them on — so that, in case of absence
or illness, one can deliver every thing up to others and know that all
will go on as usual, and that one shall never be missed.

Note. — It is often complained, that professional nurses, brought into private Why hired
famil'es, in case of sickness, make tliemselves intolerable by "ordering about" the nurses give so
other servants, under plea of not neglectmg the patient. Both things are true ; the mucb trouble,
patient is often neglected, and the servants are often unfairly " put upon." But
the fault is generally in the want of management of the head in charge. It is
surely for her to arrange both that the nurse's place is, when necessary, supple-
mented, and that the patient is never neglected — things with a little manage-
ment quite compatible, and indeed only attainable together. It is cenainly not
for the nurse to " order about' the servants.

IV. NOISE.

Unnecessary noise, or noise that creates an expectat?ion in the Unnecessary
mind, is that which hurts a patient. It is rarely the loudness of the noise,
noise, the effect upon the organ of the ear itself, which appears to
affect the sick. How well a patient will generally bear, e.g., the
putting up of a scaffolding close to the house, when he cannot bear
the talking, still less the whispering, especially if it be of a familiar
voice, outside his door.

There are certain patients, no doubt, especially where there ia
slight concussion or other disturbance of the brain, who are affected
by mere noise. But intermittent noise, or sudden 'and sharp noise,
in these as in all other cases, affects far more than continuous
noise — noise with jar far more than noise without. Of one thing
you may be certain, that anything which wakes a patient suddenly
out of his sleep will invariably put him into a state of greater
excitement, do him more serious, aye, and lasting mischief, than any
continuous noise, however loud.

Never to allow a patient to be waked, intentionally or accident- Never let a
ally, is a sine qua non of all good nursing. If he is roused out of his patient be
first sleep, he is almost certnin to have no more sleep. It is a curious ^^i^^ J^"!' ^^
but quite intelligible fact that, if a patient is waked after a few ^^^ ^^^^ ^'^^P*
hours' instead of a few minutes' sleep, he is much more likely to
sleep again. Because pain, like irritability of brain, perpetuates
and intensifies itself. If you have gained a respite of either in sleep

26

NOTES ON NURSING.

Noise which
excites expec
tatiou.

AVhispored
couver.-ation
in the room,

Or just out-
side the door

Noise of femal
dress.

you have gained more than the mere respite. Both the probability
of recurrence and of the same intensity will be diminished ; whereas
both will be terribly increased by want of sleep. This is the reason
why sleep is so all-important. This is the reason why a patient
waived in the early part of his sleep loses not only his sleep, but his
power to sleep. A healthy person who allows himseif to sleep during
the day will lose his sleep at night. But it is exactly the reverse
with the sick generally ; the more they sleep, the better will they
be able to sleep.

I have often been surprised at the thoughtlessness, (resulting
in cruelty, quite unintentionally) of friends or of doctors who will
hold a long conversation just in the room or passage adjoining to
the room of the patient, who is either every moment expecting
them to come in, or who has just seen them, and knows they are
talking about him. If he is an amiable patient, he will try to
occupy his attention elsewhere and not to listen — and this makes
matters worse — for the strain upon his attention and the effort he
makes are so great that it is well if he is not worse for hours
after. If it is a whispered conversation in the same room, then
it is absolutely cruel ; for it is impossible that the patient's attention
should not be involuntarily strained to hear. Walking on tip-toe,
doing any thing in the room very slowly, are injurious, for exactly the
same reasons. A firm light quick step, a steady quick hand are the
desiderata ; not the slow, lingering, shufHing foot, the timid, uncertain
touch. Slowness is not gentleness, though it is often mistaken for
such ; quickness, lightness, and gentleness are quite compatible.
Again, if friends ai.d doctors did but watch, as nurses can and
should watch, the features sharpening, the eyes growing almost wild,
of fever patients who are listening for the entrance from the
corridor of the persons whose voices they are hearing there, these
would never run the risk again of creating such expectation, or
irritation of mind. — Such unnecessary noise has undoubtedly induced
or aggravated delirium in many cases. I have known such — in one
case death ensued. It is but fair to say that this death was attri-
buted to fright. It was the result of a long whispered conversation,
within sight of the patient, about an impending operation ; but au}
one who has known the more than stoicism, the cheerful coolness, with
which the certainty of an operation will be accepted by any patient,
capable of bearing an operation at all, if it is properly communi-
cated to him, will hesitate to believe that it was mere fear which pro-
duced, as was averred, the fatal result in this instance. It w-as rather
the uncertainty, the strained expectation as to what was to be decided
upon.

I need hardly say that the other common cause, namely, for a

. doctor or friend to leave the patient and communicate his opinion
on the result of his visit to the friends just outside the patient's door,
or in the adjoining room, after the visit, but within hearing or know-
ledge of the patient is, if possible, worst of all.

e It is, I think, alarming, peculiarly at this time, when the female
ink-bottles are perpetually impressing upon us "w^oman's" "parti-

X0I8E. 27

cular worth and general miasionariness," to see that the dress of
women is daily more and more unfitting them for any " mission," or
usefulness at all. It is equally unfitted for all poetic and all domestic
purposes. A man is now a more handy and far less objectionable
being in a sick-room than a woman. Compelled by her dress, every
woman now either shuffles or waddles — only a man can cross
the floor of a sick-room without shaking it ! What is become of
woman's light step ? — the firm, light, quick step we have been
asking for ?

Unnecessary noise, then, is the most cruel absence of care which
can be inflicted either on sick or well. For, in all these remarks,
the sick are only mentioned as suflering in a greater proportion
than the well from precisely the same causes.

Unnecessary (although slight) noise injures a sick person much
more than necessary noise (of a much 2:reater amount).

All doctrines about mysterious affinities and aversions will be Patient's ro-
found to resolve themselves very much, if not entirely, into presence Pulsion to

, n • ii J.1 • nurses who

or absence or care in these things. rustle

A nurse who rustles ([ am speaking of nurses professional and
unprofessional) is the horror of a patient, though perhaps he does
not know why.

The fidget of silk and of crinoline, the rattling of keys, the creaking
of stays and of shoes, will do a patient more harm than all the medi-
cines in the world will do him good.

The noiseless step of woman, the noiseless drapery of woman,
are mere figures of speech in this day. Her skirts (and well if they
do not throw down some piece of furniture) will at least brush
against every article in the room as she moves.*

Again, one nurse cannot open the door without making
everything rattle. Or she opens the door unnecessarily often,
for want of remembering all the articles that might be brought in at
once.

A good nurse will always make sure that no door or window in
her patient's room shall rattle or creak ; that no blind or curtain
shall, by any change of wind through the open window, be made to
flap — especially will she be careful of all this before she leaves her
patients for the night. If you wait till your patients tell you, or
remind you of these things, where is the use of their having a nurse ?
There are more shy than exacting patients, in all classes ; and many

* Fortunate it is if her skirts do not catch fire — and if the nurse does not give Burning of tl:
herself up a sacrifice together with her patient, to be burnt in her own petticoats, crinolines.
1 wish the Registrar-General would tell us the exact number of deaths by burning
occasioned by this absurd and hideous custom. But if people will be stupid, let
them take measures to protect themselves from their own stupidity — measures
which every chemist knows, such as putting alum into starch, which prevents
starched articles of dress from blazing up.

I wish too that people who wear crinoline could see the indecency of their Indecency of
own dress as other people see it. A respectable elderly woman stooping for- the crinoiiues
ward, invested in crinoline, exposes quite as much of her own person to the patient
lying in the room as any opera dancer does on the stage. But no one will ever
tell her this unpleasant truth.

28

NOTES ON NURSING.

Hurry pecu-
liarly luutful
to sick.

ITow to visit
the sick and
not hurt them,

These things
not fancy.

Interruption
damaging to
eick

a patient pns?es a bad night, time after time, rather than remind
his nurse every night of all the things she has forgotten.

If there are blinds to your windows, always take care to have
them well up, when they are not being used. A little piece slipping
down, and flapping with every draught, will distract a patient.

All hurry or bustle is peculiarly painful to the sick. And when a
patient has compulsory occupations to engage him, instead of having
simply to amuse himself, it becomes doubly injurious. The friend
who remains standing and fidgetting about while a patient is talking
business to him, or the friend who sits and proses, the one from an
idea of not letting the patient talk, the other from an idea of amusing
him, — each is equally inconsiderate. Always sit down when a sick
person is talking business to you, show no signs of hurry, give
complete attention and full consideration if your advice is wanted,
and go away the moment the subject is ended.

Always sit within the patient's view, so that when you speak to
him he has not painfully to turn his head round in order to look at
you. Everybody involuntarily looks at the person speaking. If you
make this act a wearisome one on the part of the patient you are
doing him harm. So also if by continuing to stand you make him
continuously raise his eyes to see you. Be as motionless as possible,
and never gesticulate in speaking to the sick.

Never make a patient repeat a message or request, especially if it
be some time after. Occupied patients are often accused of doing
too much of their own business. They are instinctively right. How
often you hear the person, charged with the request of giving the
message or writing the letter, say half an hour afterwards to the
patient, " Did you appoint 12 o'clock ?" or, " What did you say was
the address ?" or ask perhaps some much more agitating question —
thus causing the patient the effort of memory, or worse still, of
decisioUj all over again. It is really less exertion to him to write his
letters himself. This is the almost universal experience of occupied
invalids.

This brings us to another caution. Never speak to an invalid
from behind, nor from the door, nor from any distance from him,
nor when he is doing anything.

The official politeness of servants in these things is so grateful to
invalids, that many prefer, without knowing why, having none but
servants about them.

These things are not fancy. If we consider that, with sick as
with well, every thought decomposes some nervous matter, — that
decomposition as well as re-composition of nervous matter is always
going on, and more quickly with the sick than with the well, — that, to
obtrude abruptly another thought upon the brain while it is in
the act of destroying nervous matter by thinking, is calling upon it
to make a new exertion, — if we consider these things, which are
facts, not fancies, we shall remember that we are doing positive
injury by interrupting, by "startling a fanciful" person, as it is
called. Alas! it is no fancy.

If the invalid is forced, hj his avocations, to continue occupations

NOISE. 29

roqutrmg much thinking, the injury is do ably great. In feeding a
patient suftering under delirium or stupor you may suffocate him,
by giving him his food suddenly, but if you rub his lips gently
with a spoon and thus attract his attention, he will swallow the food
unconsciously, but with perfect safety. Thus it is with the brain.
If you offer it a thought, especially one requiring a decision, abruptly,
you do it a real not fanciful injury. Never speak to a sick person
suddenly; but, at the same time, do not keep his expectation on the
tiptoe.

This rule, indeed, applies to the well quite as much as to the sick. And to well.
I have never known persons who exposed themselves for years to
constant interruption wiio did not muddle away their intellects by it
at last. The process with them may be accomplished without pain.
With the sick, pain gives warning of the injury.

Do not meet or overtake a patient who is moving about in order Keeping a
to speak to him, or to give him any message or letter. Tou might patient
just as well give him a box on the ear. I have seen a patient fall standing.
flat on the ground who was standing when his nurse came into the
room. This was an accident which might have happened to the
most careful nurse. But the other is done with intention. A
patient in such a state is not going to the East Indies. If you would
wait ten seconds, or walk ten yards further, any promenade he could
make would be over. You do not know the effort it is to a patient
to remain standing for even a quarter of a minute to listen to you.
If I had not seen the thing done by the kindest nurses and friends,
I should have thought this caution quite superfluous.*

Patients are often accused of being able to " do much more when Tatients dread
nobody is by." It is quite true that they can. Unless nurses can surprise,
be brought to attend to considerations of the kind of which we have
given here but a few specimens, a very weak patient finds it really
much less exertion to do things for himself than to ask for them.
And he will, in order to do them, (very innocently and from
instinct) calculate the time his nurse is likely to be absent, from a
fear of her " coming in upon" him or speaking to him, just at the
moment when he finds it quite as much as he can do to crawl from
his bed to his chair, or from one room to another, or down stairs, or
out of doors for a few minutes. Some extra call made upon his
attention at that moment will quite upset him. In these cases you
may be sure that a patient in the state we have described does not
make such exertions more than once or twice a-day, and probably

* It ig absolutely essential that a nurse should lay this down as a positive rule Never speak ta
to herself, never to speak to any patient who is standing or moving, as 1 ng as a patient in
she exercises so little observation as not to know when a patient cannot bear it. the act of
I am satisfied that many of the accidents which happen from feeble patients tumb- moving,
ling down stairs, fainting after getting up, &c., happen solely fro.n the nurse pop-
ping out of a door to speak to the patient just at that moment ; or from his fearing
that she will do so. And that if the patient were even left to himself, till he ciux
sit down, such aeci'lents would much seldomer occur. If the nurse accompanies
the patient let her not call upon him to speak. It is incredible that nurses can-
not piciure to themselves the strain upon the heart, the lungs, and the braia
which the act of moving is to any iecblc pa'icnt.

30 NOTES ON NCIISING.

much about the same hour every day. And it is hard, indeed, if
nurse and friends cannot calculate so as to let him make them
undisturbed. Eeraember, that many patients can walk who cannot
stand or even sit up. Standing is, of all positions, the most trying
to a weak patient.

Everytliing you do in a patient's room, after he is ''put up " for
the night, increases tenfold the risk of his having a bad night.
But, if you rouse hira up after he has fallen asleep, you do not risk,
you secure him a bad night.

One hint I would give to all who attend or visit the sick, to
all who have to pronounce an opinion upon sickness or its pro-
gress. Come back and look at your patient after he has had
an hour's animated conversation with you. It is the best test of
his real state we know. But never pronounce upon him from
merely seeing what he does, or how he looks, during such a conver-
sation. Learn also carefully and exactly, if you can, how he passed
the night after it.
Effects of over- People rarely, if ever,f[nnt while making an exertion. It is after
gi^k" ^^^ ^^ ^^ ^^ over. Indeed, almost every effect of over-exertion appears
after, not during such exertion. It is the highest folly to judge of
the sick, as is so often done, when you see them merely during a
period of excitement. People have very often died of that which, it
has been proclaimed at the time, has " done them no harm."^'

Eemember never to lean against, sit upon, or unnecessarily
shake, or even touch the bed in which a patient lies. This is inva-
riably a painful annoyance. If you shake the chair on which he
sits, he has a point by which to steady himself, in his feet. But on
a bed or sofa, he is entirely at your mercy, and he feels every jar
you give him all through him.
Jjitierence \^ all that we have said, both here and elsewhere, let it be

and^fanev^^ distinctly understood that we are not speaking of hypochondriacs,
patients. '^^ distinguish between real and fancied disease forms an important

branch of the education of a nurse. To manage fancy patients forms
an important branch of her duties. But the nursing which real and
that which fancied patients require is of different, or rather of
opposite, character. And the latter will not be spoken of here.
Indeed, many of the symptoms which are here mentioned are those
which distinguish real from fancied disease.

Oareless obser- * -'^s ^"^ old experienced nurse, I do most earnestly deprecate all such careless
vation of the ^vords. I have known patients delirious all night, after seeing a visitor who
results of care- "-'al'ed them " better," thought they "only wanted a little amusement," and who
less visits. oame again, saying, "I hope you were not the worse for my visit," neither wait-

ing for an answer, nor even looking at the case. Ko r.al patient will ever say,
" Yes, but I was a great deal the worrrc."

It is not, however, either death or delirium of which, in these cases, there is
most danger to the patient. Unperceived consequences are far more likely to
ensue. You will have impunity— the poor patient will not. That is, the patient,
will suflTer, althoiigh neither he nor the inflictor of the injury will attribute it to
its real cause. It will not be directly traceable, except by a very careful
oi)servant nurse. The patient will often not even mention what has done him
laoKt barm.

NOISE. 31

It is true that hypochondriacs very often do that behind a nurse's
back which they would not do before her face. Many such I have
had as patients who scarcely ate anything at their regular meals ;
but if you concealed food for them in a drawer, they would take it
at night or in secret. But this is from quite a different motive.
They do it from the wish to conceal. AVhereas the real patient
will often boast to his nurse or doctor, if these do not shake their
heads at him, of how much he has done, or eaten, or walked. To
return to real disease.

Conciseness and decision are, above all things, necessary with the Conciseness
sick. Let your thought expressed to them be concisely and decidedly necessary with
expressed. What doubt and hesitation there may be in your own Sick,
mind must never be comtiiunicaced to theirs, not even (I would
rather say especially not) in little things. I^et your doubt be to
yourself, your decision to them. People who think outside their
"heads, the whole process of whose thought appears, like Homer's, in
the act of secretion, who tell everything that led them towards this
conclusion and away from that, ought never to be with the sick.

Irresolution is what all patients most dread. Eather than meet Irresolution
this in others, they will collect all their data, and make up their minds most painful
for themselves. A change of mind in others, whether it is regarding to them
an operation, or re-writing a letter, always injures the patient
more than the being called upon to make up his mind to the most
dreaded or difficult decision. Farther than this, in very many cases,
the imagination in disease is far more active and vivid than it is in
health. If you propose to the patient change of air to one place
one hour, and to another the next, he has, in each case, immediately
constituted himself in imagination the tenant of the place, gone over
the whole premises in idea, and you have tired him as much by
displacing his imagination, as if you had actually carried him over
both places.

Above all leave the sick room quickly and come into it quickly,
not suddenly, not with a rush. But don't let the patient be wearily
waiting for when you will be out of the room or when you will be in
it. Conciseness and decision in your movements, as well as your
words, are necessary in the sick room, as necessary as absence of
hurry and bustle. To possess yourself entirely will ensure you from
either failing — either loitering or hurrying.

If a patient has to see, not only to his own but also to his nurse's What apatieni
punctuaiity, or perseverance, or readiness, or calmness, to any or all must not have
of these things, he is far better without that nurse than with her — ^ see to.
however valuable and handy her services may otherwise be to him,
and however incapable he may be of rendering them to himself.

With regard to reading aloud in the sick room, my experience Reading
is, that when the sick are too ill to read to themselves, they can a!oud.
seldom bear to be read to. Children, eye-patients, and uneducated
persons are exceptions, or where there is any mechanical difficulty
in reading. People who like to be read to, have generally not much
the matter with them; while in fevers, or where there is much irri-
tability of brain, the effort of listening to reading aloud has often

82 NOTES ON NURSING.

brought on delirium. I speak with great diffidence; because there
is an ahnost universal impression that it is sparing the sick to read
aloud to them. But two things are certain : —
Read aloud ^j^ ^ jf there is some matter which must be read to a sick

diTinctlv and P^^^^n, do it slowly. People often think that the way to get it
steadily Vo the over with least fatigue to him is to get it over in least time. They
sick. gabble ; they plunge and gallop through the reading. There never

was a greater mistake. Houdin, the conjuror, says that the way to
make a story seem short is to tell it slowly. So it is with reading
to the sick. I have often heard a patient say to such a mistaken
reader, "Don't read it to me; tell it me."* Unconsciously he is
aware that this will regulate the plunging, the reading with unequal
paces, slurring over one part, instead of leaving it out altogether,
if it is unimportant, and mumbling another. If the reader lets his
cwn attention wander, and then stops to read up to himself, or finds
he has read the wrong bit, then it is all over with the poor patient's
chance of not suffering. Very few people know how to read to the
sick ; very few read aloud as pleasantly even as they speak. In
reading they sing, they hesitate, they stammer, they hurry, they
mumble; when in speaking they do none of these things. Eeading
aloud to the sick ought always to be rather slow, and exceedingly
distinct, but not mouthing — rather monotonous, but not sing song
— rather loud, but not noisy — and, above all, not too long. Be very
sure of what your patient can bear.
1 ^lV^f[^ (2.) The extraordinary habit of reading to oneself in a sick room,

and" starts to ^^^^ reading aloud to the patient any bits which will amuse him or
the sick. more often the reader, is unaccountably thoughtless. What do you

think the patient is thinking of during your gaps of non-reading ?
Do you think that he amuses himself upon what you have read for
precisely the time it pleases you to go on reading to yourself, and
that his attention is ready for something else at precisely the time it
pleases you to begin reading again ? AVhether the person thus read
to be sick or well, whether he be doing nothing or doing something
else while being thus read to, the self-absorption and want of obser-
vation of the person who does it, is equally difficult to understand —
although very often the readme is too amiable to say how much it
disturbs him.
^ I ^ , One thing more : — From the flimsy manner in which most modern

over ea . houses^ are built, where every step on the stairs, and along the
floors, is felt all over the house ; the higher the story, the greater
the vibration. It is inconceivable how much the sick suffer by
having anybody overhead. In the solidly built old houses, which,
fortunately, most hospitals are, the noise and shaking is comparatively
trifling. But it is a serious cause of suflering, in lightly built houses,
and with the irritability peculiar to some diseases. i3etter far put
such patients at the top of the house, even with the additional
fatigue of stairs, if you cannot secure the room above them being

The sick would

ffSffir ^t"^^ • * ^^^^ children, if not too shy to speak, will always express this wish. They

it rS to^.W ^"^^'^"^^^y r^^^er a story to be told to theui, rather than read to them.

VAEIETT. 33

untenanted; you may otherwise bring on a state of restlessness which
no opium will subdue. Do not neglect the warning, when a patient
tells you that he " Eeels every step above him to cross his heart."
Remember that every noise a patient cannot see partakes of the
character of suddenness to him; and I am persuaded that patients
with these peculiarly irritable nerves, are positively less injured by
having persons in the same room with them than overhead, or
separated by only a thin compartment. Any sacrifice to secure silence
for these cases is worth while, because no air, however good, no
attendance, however careful, will do anything for such cases without
quiet.

Note. — The effect of music upon the sick has been scarcely at all noticed. Musiv.
In fact, its expensiveness, as it is now, makes any general application of it quite
out of the question, I will only remark here, that wind instruments, including
the human voice, and stringed instruments, capable of continuous sound, have
generally a beneficent effect — Avhile the piano-forte, with such instrumeuts as have
no continuity of sound, has just the reverse. The finest piano-forte playing will
damage the sick, while an air, like ''Home, sweet home," or "Assisa a pi^ d'un
salice," on the most ordinary grinding organ will sensibly soothe them — and this
quite independent of association

y. VARIETY.

To any but an old nurse, or an old patient, the degree would be Variety a
quite inconceivable to which the nerves of the sick suffer from seeing means oi
the same walls, the same ceiling, the same surroundings during a ^^c<^^'^0'-
long confinement to one or two rooms.

The superior cheerfulness of persons suffering severe paroxysms
of pain over that of persons suffering from nervous debility has often
been remarked upon, and attributed to the enjoyment of the former
of their intervals of respite. I incline to think that the majority of
cheerful cases is to be found among those patients who are not con-
fined to one room, whatever their suffering, and that the majority of
depressed cases will be seen among those subjected to a long
monotony of objects about them.

The nervous frame really suffers as much from this as the diges-
tive organs from long monotony of diet, as e.y. the soldier from his
twenty-one years' " boiled beef"

The effect in sickness of beautiful objects, of variety of objects, <-'olour and
and especially of brilliancy of colour is hardly at all appreciated. form means of

Such cravings are usually called the "fancies" of patients. And
often doubtless patients have "fancies," as, e.ff. when they desire
two contradictions. But much more often, their (so called) "fancies"
are the most valuable indications of what is necessary for their
recovery. And it would be well if nurses would watch these (so
called) "fancies" closely.

I. have seen, in fevers (and felt, when I was a fever patient myself)
the most acute suffering produced from the patient (in a hut) not
being able to see out of window, and the knots in the wooa

34 NOTES ON NUESINO.

being the only view. I shall never forget the rnptuie of fever
patients over a bunch of bright-coloured flowers. 1 remember (in
my own case) a nosegay of wild flowers being sent me, and from
that moment recovery becoming more rapid.

This is no People say the effect is only on the mind. It is no such thing.

fancy. ^he effect is on the body, too. Little as we know about the way in

which we are affected by form, by colour, and light, we do know this,
that they have an actual physical effect.

Variety of form and brilliancy of colour in the objects presented
to patients are actual means of recovery.

But it must be slow variety, e.g., if you shew a patient ten or
twelve engravings successively, teu-to-one that he does not become
cold and faint, or feverish, or even sick ; but hang one up opposite
him, one on each successive day, or week, or month, and he will revel
in the variety.

Flowers, The folly and ignorance which reign too often supreme over the

sick-room, cannot be better exemplified than by this. "While the
nurse will leave the patient stewing in a corrupting atmosphere,
the best ingredient of which is carbonic acid ; she will deny him, on
the plea of unhealthiness, a glass of cut-flowers, or a growing plant.
IS'ow, no one ever saw " overcrowding" by plants in a room or ward.
And the carbonic acid they give off at nights would not poison a fly.
Nav, in overcrowded rooms, they actually absorb carbonic acid and
give off oxygen. Cut-flowers also decompose water and produce
oxygen gas. It is true there are certain flowers, e.g., lilies, the smell
of "which is said to depress the nervous system. These are easily
known by the smell, and can be avoided.

Eflfect of body Volumes are now written and spoken upon the eflect of the mind

on mind. upon the body. Much of it is true. But I wish a little more was

thought of the effect of the body on the mind. Tou who believe
yourselves overwhelmed witb anxieties, but are able every day to
walk up Eegent-street, or out in the country, to take your meals with
others in other rooms, &c., &c., you little know how much your
anxieties are thereby lightened ; you little know how intensified they
become to those who can have no change ;* how the very walls of
their sick rooms seem hung with their cares ; how the ghosts of
their troubles haunt their beds ; how impossible it is for them to
escape from a pursuing thought without some help from variety.

A patient can just as much move his leg when it is fractured as
change his thoughts when no external help ffom variety is given
him. This is, indeed, one of the main sufferings of sickness ; just

Sick suffer to * It is a matter of painful wonder to the sick themselves how much painful

excess from ideas predominate ovir pleasurable ones in their impressions; they reason with

mental as well themselves ; they think themselves ungrateful ; it is all of no use. The fad is.

as bodily pain, th^t these painful impressions are far better dismissed by a real laugh, if you can

excite one by books or conversation, than by any direct reasoning, or if the

patient is too weak to laugh, some impression from nature is what he wants, i

have mentioned the cruelty of letting him stare at a dead wall. In many

diseases, especially in convalescence from fever, that wall will appear to make all

sorts of faces at him; now flowers never do this. Form, colour, will free your

patient from his painful ideas better than any argument.

YAETETT. 35

as the fixed posture is one of the main sufferings of the broken
limb.

It is an ever recurring wonder to see educated people, who Help the sicl:-.
call themselves nurses, acting thus. They vary their own objects, *<^ ^^^^'t'^^ir
their own employments many times a day ; and while nursiug (I) thoughts,
some bed-ridden sufferer, they let him lie there staring at a dead
wall, without any change of object to enable him to vary his thoughts ;
and it never even occurs to them, at least to move his bed so that he
can look out of window. No, the bed is to be always left in the-
darkest, dullest, remotest, part of the room.*

I think it is a very common error among the well to think that
"with a little more self-control" the sick might, if they choose,
"dismiss painful thoughts" which "aggravate their disease," &c.
Believe me, almost any sick person, who behaves decently well,
exercises more self-control every moment of his day than you will
ever know till you are sick yourself. Almost every step that crosses
his room is painful to him ; almost every thought that crosses his
brain is painful to him ; and if he can speak without being savage,
and look without being unpleasant, he is exercising self-control.

Suppose you have been up all night, and instead of being allowed
to have your cup of tea, you were to be told that you ought to
" exercise self-control," what should you say ? Now, the nerves of
the sick are always in the state that yours are in after you have been
up all night.

AVe will suppose the diet of the sick to be cared for. Then, this Supply to the
state of nerves is most frequently to be relieved by care in affording ^i-J^ the defect
them a pleasant view, a judicious variety as to flowers,t and pretty ^^"^^'^"^^
things. Light by itself will often relieve it. The craving for "the ^ °^^"
return of day," which the sick so constantly evince, is generally
nothing but the desire for light, the remembrance of the relief which
a variety of objects before the eye affords to the harassed sick mind.

Again, every man and every woman has some amount of manual
employn:ient, excepting a few fine ladies, who do not even dress
themselves, and who are virtually in the same category, as to nerves,
as the sick. Now, you can have no idea of the relief which manual
labour is to you — of the degree to whicli the deprivation of manual

* I rememljer a cose in point. A man received an injury to the spine, from Desperate de-
an accident, which after a long confinement ended in death. He was a woricman sire in the
— had not in his composition a single grain of what is called " enthusiasm lor sick to '• see
nature," — but he was desperate to " see once more out of window." His nurse out of win-
actually got him on her back, and managed to perch him up at the window for an dow."
instant, "to see out." The consequence to the poor nuree was a serious illness,
which nearly proved fatal. The man never knew it ; but a great many other
people did. Yet the consequence in none of their minds, so far as I know, was
the conviction that the craving for variety in the starving eye, is just as desperate
as that for food in the starving stomach, and tempts the famishing creature in
either case to steal for its satisfaction. No other word will express it but "des-
peration." And it sets the seal of ignorance and stupidity just as much on the
governors and attendants of the sick if they do not provide the sick-bed with a
"view" of some kind, as if they did not provide tht^ hospital with a kitchen.

t No one Tvho has watched the sick can doubt the fact, that some feel stiniulu? Physical etlect
from locking at sjarlet flowers, exhaustion from looking at deep blue, &c. oi colour.

JJ 2

3d 2nOTES o>' kuhsin-g^

employ merit Increases the peculiar irritability ircm rvKIcli n>auy sicli
sufier.

A little needle-work, a little writing, a little cleaning, would be the
greatest relief the sick could have, if they could do it; these are Ihe
greatest relief to you, though you do not know it. Eeading, thouge
ifc is often the only thing the sick can do, is not this relief. Bearing
this in mind, bearing in mind that you have all these variciies cl;'
employment which the sick cannot have, bear also in mind to obtain
for them all the varieties which they can enjoy.

I need hardly say that I am well aware that excess in needle-work,
in writing, in any other continuous employment, will produce the
same irritability that defect in manual employment (as one cause)
produces in the sick.

VI. TAKING POOD.

VVant of alien- Every careful observer of the sick will agree in this that
*'^^*'^ *^^"'"^ thousands of patients are annually starved in the midst of plenty,
0 a 'ing too . ^^^^ ^ant of attention to the ways which alone make it possible for
them to take food. This want of attention is as remarkable in those
who urge upon the sick to do what is quite impossible to them, as in
the sick themselves who will not make the effort to do what is per-
fectly possible to them.

Tor instance, to the large majority of very weak patients it is
quite impossible to take any solid food before 11 a..m, nor then, if
their strength is still further exhausted by fasting till that hour.
For weak patients have generalh' feverish nights and, in the morning,
dry mouths ; and, if they could eat with those dry mouths, it would
be the worse for them. A spoonful of beef-tea, of arrowroot and
wine, of egg flip, every hour, will give them the requisite nourish-
ment, and prevent them from being too much exhausted to take at a
later hour the solid food, which is necessary for their recovery. And
every patient who can swallow at all can swallow these liquid things,
if he chooses. But how often do we hear a mutton-chop, an Qgg^ a
bit of bacon, ordered to a patient for breakfast, to whom (as a
moment's consideration would show us) it must be quite impossible
to masticate such things at that hour.

Again, a nurse is ordered to give a patient a tea-cup full of some
article of food cTcry three hours. The patient's stomach rejects it.
If so, try a table-spoon full every hour ; if this will not do, a tea-spoon
full every quarter of an hour.

I am bound to say, that I think more patients are lost by want of

care and ingenuity in these momentous minutiae in private nursing

than in public hospitals. And 1 think there is more of the entente

cordiale to assist one another's hands between the doctor and his head

nurse in the latter institutions, than between the doctor and the

patient's friends in the private house.

LiFe^often j^- ^^^ ^-^ |^^^ know the consequences which may ensue, in very

minuleTi " ^'tak patients, from ten minutes' fasting or repletion, (I call it repletion

taking food.

TAKI^'G FOOD. 37

when they are obliged to let too small an interval elapse between
taking food and some other exertion, owing to the nurse's unpunctu-
alitj), we should be more careful never to let this occur. In very
weak patients there is often a nervous difficulty of swallowing, which
is so much increased by any other call upon their strength that, un-
less they have their food punctually at the minute, which minute
again must be arranged so as to fall in with no other minute's occu-
pation, they can take nothing till the next respite occurs — so
that an unpunctuality or delay of ten minutes may verv well turn
out to be one of two or three hours. And why is it not as easy
to be punctual to a minute ? Life often literally hangs upon these
minutes.

In acute cases, where life or death is to be determined in a few
hours, these matters are very generally attended to, especially in
Hospitals ; and the number of cases is large where the patient is, as
it were, brought back to life by exceeding care on the part of the
Doctor or Nurse, or both, in ordering and giving nourishment with
minute selection and punctuality.

But, in chronic cases, lasting over months and years, where the Patients often
fatal issue is often determined at last by mere protracted starvation, starved to
I had rather not enumerate the instances which 1 have known where death in
a little ingenuity, and a great deal of perseverance, might, in all ^ ^^°^^" cases-
probability, have averted the result. The consulting the hours when
the patient can take food, the observation of the times, often varying,
when he is most faint, the altering seasons of taking food, in order to
anticipate and prevent such times — all this, which requires observa-
tion, ingenuity, and perseverance (and these really constitute the good
Nurse), might save more lives than we wot of.

To leave the patient's untasted food by his side, from meal to p^Q^i never to
meal, in hopes that he will eat it in the interval, is simply to prevent be left by the
him from taking any food at all. I have known patients literally patient's side,
incapacitated from taking one article of food after another, by this
piece of ignorance. Let the food come at the right time, and be
taken away, eaten or uneaten, at the right time; but never let a
patient have " something always standing " by him, if you don't wish
to disgust him of everything.

On the other hand, I have known a patient's life saved (he was
sinking for want of food) by the simple question, put to him by the
doctor, " But is there no hour when you feel you could eat?" " Oh,
yes," he said, " I could always take something at — o'clock and —
o'clock." The thing was 'tried and succeeded. Patients very
seldom, however, can tell this ; it is for you to watch and find it out.

A patient should, if possible, not see or smell either the food of Patient had

others, or a greater amount of food than he himself can consume at ^^''^^^^."^^ff,
,.' ^ , r« 1 , 11 1 1 J -^ • ^1 4-4- more food thatt

one tune, or even hear food talked about or see it m the raw state, j^.^ ^^^,^^

I know of no exception to the above rule. The breaking of it always

induces a greater or less incapacity of taking food.

In hospital wards it is of course impossible to observe all this ;

and in single wards, where a patient must be continuously and closely

watched, it is frequently impossible to relieve the attendant, so that

38 NOTES ON NUBSING.

his or her own meals can be taken out of the ward. But it is not the
less true that, in such cases, even where the patient is not himself
aware of it, his possibility of taking food is limited by seeing the
attendant eating meals under his observation. In some cases the
sick are aware of it, and complain. A case where the patient was
supposed to be insensible, but complained as soon as able to speak,
is now present to my recollection.

Hemember, however, that the extreme punctuality in well-ordered
hospitals, the rule that nothing shall be done in the ward while the
.patients are having their meals, go fur to counterbalance what un-
avoidable evil there is in having patients together. I have often seen
the private nurse go on dusting or fidgeting about in a sick room all
the while the patient is eating, or trying to eat.

That the more alone an invalid can be when taking food, the
better, is unquestionable ; and, even if he must be fed, the nurse
should not allow him to talk, or talk to him, especially about food,
while eating.

AYhen a person is compelled, by the pressure of occupation, to
continue his business while sick, it ought to be a rule wcthout ant
EXCEPTION wiiATEA^ER, that no ouo shall bring business to him or
talk to him while he is taking food, nor go on talking to him on inte-
resting subjects up to the last moment before his meals, nor make an
engagement with him immediately after, so that there be any hurry
of mind while taking them.

Upon the observance of these rules, especially the first, often

depends the patient's capability of taking food at all, or, if he is

amiable and forces himself to take food, of deriving any nourishment

from it.

You cannot be A nurse should never put before a patient milk that is sour, meat

too carefulas qj. gQ^^p ^j^^t is turned, an egg that is bad, or vegetables underdone.

to quality in y^^. ^f^^^-^ j j^jj^g gg^^^ these thins^s brought in to the sick in a state

sick diet. ^ ,, .Ml i * ° ^^1 5 T^ •

perfectly perceptible to every nose or eye except the nurse s. it is

here that the clever nurse appears ; she will not bring in the peccant
article, but, not to disappoint the patient, she will whip up something
else in a few minutes. Remember that sick cookery should half do
the work of your poor patient's weak digestion. But if you further
impair it with your bad articles, I know not what is to become of
him or of it.

If the nurse is an intelligent being, and not a mere carrier of
diets to and from the patient, let her exercise her intelligence in
these things. How often we have known a patient eat nothing at
all in the day, because one meal was it^ft untasted (at that time he
was incapable of eating), at another the milk was sour, the third was
spoiled by some other accident. And it never occurred to the nurse
to extemporize scm3 expedient, — it never occurred to her that as he
had had no solid food that day, he might eat a bit of toast (say)
with his tea in the evening, or he might have some meal an hour
earlier. A patient who cannot touch his dinner at two, will often
accept it gladly, if brought to liim at seven. But somehow nurses never
"think of these things." One would imadue they did not consider

WHAT FOOD ? 39

themselves bound to exercise their judgment; they leave it to the
patient. Now I am quite sure that it is better for a patient rather
to suffer these neglects than to try to teach his nurse to nurse him,
if she does not know how. It ruffles him, and if he is ill he is in
no condition to teach, especially upon himself. The above remarks
apply much more to private nursing than to hospitals.

I would say to the nurse, have a rule of thought about your JiTurse must
patient's diet ; consider, remember how much he has had, and how have some ruk-
much he ought to have to-day. Generally, the only rule of the ^[ ^hougli.
private patient's diet is what the nurse has to give. It is true she ijf ent's'd* t
cannot give him what she has not got ; but his stomach does not wait
for her convenience, or even her necessity.* If it is used to having
its stimulus at one hour to-day, and to-morrow it does not have
it, because she has failed in getting it, he will suffer. She must
be always exercising her ingenuity to supply defects, and to remedy
accidents which will happen among the best contrivers, but from
which the patient does not suffer the less, because " they cannot be
helped."

One very minute caution, — take care not to spill into your Keep your
patient's saucer, in other words, take care that the outside bottom patient's cup
rim of his cup shall be quite dry and clean ; if, every time he lifts his ^O' under-
cup to his lips, he has to carry the saucer with it, or else to droj) ^^ '^"*
the liquid upon, and to soil his sheet, or his bed-gown, or pillow, or if
he is sitting up, his dress, you have no idea what a difference this
minute want of care on your part makes to his comfort and even to
his willingness for food

YII. WHAT FOOD?

I will mention one or two of the most common errors among Common
women in charge of sick respecting sick diet. One is the belief that errors in diet,
beef tea is the most nutritive of all articles. Now, just try and
boil down a lb. of beef into beef tea, evaporate your beef tea, and Beef tea.
see what is left of your beef. Tou will find that there is barely a tea-
spoonful of solid nourishment to half a pint of water in beef tea; — never-
theless there is a certain reparative quality in it, we do not know
what, as there is in tea; — but it may safely be given in almost any
inflammatory disease, and is as little to be depended upon with tht^
healthy or convalescent where much nourishment is required. Again,
it is an ever ready saw that an egg is equivalent to a lb. of meat, —
whereas it is not at all so. Also, it is seldom noticed with how many

* Why, because the nurse has not got some food to-day which the patient takes, Xurse must
can the patient wait four hours for food to day, who could not wait two hours yester- have some rule
day 1 Yet this is the only logic one generally hears. On the other hand, the other of time al»out
logic, viz., of the nurse giving a patient a thing because she has got it, is equally the patient's
fatal. If she happens to have fresh jelly, or fresh fruit, she will frequently give diet,
it to the patient half-an hour after his dinner, or at his dinner, when he cannot
possibly eat that and the broth too— or wor.se still leave it by his bod side till he
is so sickened with the sight of it, that he cannot «at it at all.

40

N'OTES ON NUBSTNG.

Eg-gs.

Meat without
vegetables.

Arrowroot.

Milk, butter,
cream, &c.

Intelligent
cravings of
particular side
for particular
articles of
diet.

patients, particularly of nervous or bilious teiriperament, eggs disagree.
All puddings made with eggs, are distasteful to them in eoiisequence.
An egg, whipped up with wine, is often the only form in which they
can take this kind of nourishment. Again, if the patient has attained
to eating meat, it is supposed that to give him meat is the
only thing needful for his recovery ; w-hereas scorbutic sores have
been actually known to appear among sick persons living in the
midst of plenty in England, which could be traced to no other source
than this, viz. : that the nurse, depending on. meat alone, had allowed
the patient to be without vegetables for a considerable time, these
latter being so badly cooked that he always left them untouched.
Arrowroot is another grand dependence of the nurse. As a vehicle
for wine, and as a restorative quickly prepared, it is all very well.
But it is nothing but starch and water. Flour is both more nutri-
tive, and less liable to ferment, and is preferable wherever it can be
used.

Again, milk and the preparations from milk, are a most important
article of food for the sick. Butter is the lightest kind of animal fat,
and though it wants the sugar and some of the other elements which
there are in milk, yet it is most valuable both in itself and in enabling
the patient to eat more bread. Elour, oats, groats, barley, and their
kind, are as we have already said, preferable in all their preparations
to all the preparations of arrow root, sago, tapioca, and their kind.
Cream, in many long chronic diseases, is quite irreplaceable by
any other article whatever. It seems to act in the same manner
as beef tea, and to most it is much easier of digestion than milk.
In fact, it seldom disagrees. Cheese is not usually digestible by the
sick, but it is pure nourishment for repairing waste ; and I have
seen sick, and not a few either, whose craving for cheese shewed how
much it was needed by them.*

But, if fresh milk is so valuable a food for the sick, the least change
or sourness in it, makes it of all articles, perhaps, the most injurious ;
diarrhoea is a common result of fresh milk allowed to become at all
sour. The nurse therefore ought to exercise her utmost care in this.
In large institutions for the sick, even the poorest, the utmost care is
exercised. Wenham Lake ice is used for this express purpose every
summer, while the private patient, perhaps, never tastes a drop ol
milk that is not sour, all through the hot weather, so little does the
private nurse understand the necessity of such care. Yet, if you
consider that the only drop of real nourishment in your patient's tea
is the drop of milk, and how much almost all English patients depend

* In the diseases produced by bad food, such as scorbutic dysentery and
diarrhoea, the patient's stomach often craves for and digests things, some of which
certainly would be laid down in no dietary that ever was invented for sick, and
especially not for such sick. These are fruit, pickles, jams, gingerbread, fat of
ham or of bacon, suet, cheese, butter, milk. These cases I have seen not by ones,
nor by tens, but by hundreds. And the patient's stomach was right and the book
was wrong. The articles craved for, in these ea?es, might have been principally
arranged under the two heads of fat and vegetable acids.

There is often a marked difference between men and women in this matter
of sick feeding. Women's digestion is generally slower.

WHAT FOOD ? 41

Upon their tea, you will see the great importance of not deprivin,^
jour patient of this drop of milk. Buttermilk, a totally dilTereiit
thing, is often very useful, especially in fevers.

In laying down rules of diet, by the amounts of " solid nutri- Sweet things
ment " in dilferent kinds of food, it is constantly lost sight of what
the patient requires to repair bis waste, what he can take and wbnt
be can't. You cannot diet a patient from a book, you cannot make
up the iiuman body as you would make up a prescription, — so many
parts ''carboniferous," so many parts "nitrogenous" will consti-
tute a perfect diet for the patient. The nurse's observation here
will materially assist the doctor — the patient's "fancies" will
materially assist the nurse. For instance, sugar is one of the most
nutritive of all articles, being pure carbon, and is particularly recom-
mended in some books. But the vast majority of all patients in
England, young and old, male and female, rich and poor, hospital and
private, dislike sweet things, — and while I have never known a ]ierson
take to sweets when he was ill who disliked them when he was well,
I have known many fond of them when in health, who in sickness would
leave off anything sweet, even to sugar in tea, — sweet puddings,
sweet drinks, are their aversion ; the furred tongue almost always
likes what is sharp or pungent. Scorbutic patients are an exception,
they often crave for sweetmeats and jams.

"^Jelly is another article of diet in great favour with nurses and Jelly,
friends of the sick ; even if it could be eaten solid, it would not
nourish, but it is simply the height of folly to take ^ oz. of gelatine
and make it into a certain bulk by dissolving it in water and then to
give it to the sick, as if the mere bulk represented nourishment. It
is now known that jelly does not nourish, that it has a tendency to
produce diarrhcea, — and to trust to it to repair the waste of a diseased
constitution is simply to starve the sick under the guise of feeding
them. If 100 spoonfuls of jelly were given in the course of the day,
you would have given one spoonlul of gelatine, which spoonful has
no nutritive power whatever.

And, nevertheless, gelatine contains a large quantity of nitrogen,
which is one of the most powerful elements in nutrition; on the
other hand, beef tea may be chosen as an illustration of great nutrient
power in sickness, co-existing with a very small amount of solid
nitrogenous m.atter.

Dr. Christison says that " every one will be struck with the readi- Beef tea.
ness w^ith which" certain classes of "patients will often take diluted
meat juice or beef tea repeatedly, when they refuse all other kinds of
food." This is particularly remarkable in " cases of gastric fever,
in which," he says, "little*^ or nothing else besides beef tea or diluted
meat juice" has been taken for weeks or even months, " and yet a
pint of beef tea contains scarcely joz. of anything but ^yater," — the
result is so strikmg that he asks what is its mode of action ? " Not
simply nutrient — I oz. of the most nutritive material cannot nearly
replace the daily wear and tear of the tissues in any circumstances.
Possibly," he says, "it belongs to a new denomination of remedies."

It has been observed that a small quantity of beef tea added to

42

NOTES ON NURSING.

Observation,
not chemi-sfrj-j
must decide
sick diet.

Home mad^
bread.

Sound obser-
vation has
scarcely y€t
been brought
to bear on -sick
diet.

otlier articles of nutrition augments their power out of all proportion
to the additional amount ot solid matter.

The reason why jelly should be innutritions and beef tea nutri-
tious to the sick, is a secret yet undiscovered, but it clearly shows
that careful observation of the sick is the only clue to the best
dietary.

Cliemistry has as yet afforded little insight into the dieting of sick.
All that chemistry can tell us is the amount of "carboniferous" or
" nitrogenous " elements discoverable in diflerent dietetic articles.
It has given us lists of dietetic substances, arranged in the order of
their richness in one or other of these principles ; but that is all. In
the great majority of cases, the stomach of the patient is guided by
other principles of selection than merely the amount of carbon or
nitrogen in tlie diet. No doubt, in this as in other things, nature has
very definite rules for her guidance, but these rules can only be
ascertained by the most careful observation at the bed-side. She
there tenches us that living chemistry, the chemistry of reparation, is
something diii'erent from the chemit^try of the laboratory. Organic
chemistry is useful, as all knowledge is, when we come face to face
with nature ; but it by no means follows that we should learn in the
laboratory any one of the reparative processes going on in disease.

Again, the nutritive power of milk and of the preparations from
milk, is very much undervalued ; there is nearly as much nourish-
ment in half a pint of milk as there is in a quarter of a lb. of meat.
But this is not the whole question or nearly the whole. The main
question is what the patient's stomach can assimilate or derive
nourishment from, and of this the patient's stomach is the sole judge.
Chemistry cannot tell this. The patient's stomach must be its own
chemist. The diet which will keep the healthy man healthy, will kill
the sick one. The same beef which is the most nutritive of all meat
and which nourishes the healthy man, is the least nourishing of all
food to the sick man, whose half-dead stomach can assimilate no part
of it, that is, make no food out of it. On a diet of beef tea healthy
men on the other hand speedily lose their strength.

I have known patients live for many months without touching
bread, because they could not eat baker's bread. These were mostly
country patients, but not all. Home-made bread or brown bread is
a most important article of diet for many patients. The use of
aperients may be entirely superseded by it. Oat cake is another.

To watch for the opinions, then, which the patient's stomach gives,
rather than to read " analyses of foods," is the business of all those
who have to settle what the patient is to eat — perhaps the most
important thing to be provided for him after the air he is to breathe.
Now the medical man who sees the patient only once a day or even
only once or twice a week, cannot possibly tell this without the
assistance of the patient himself, or of those who are in constant
observation on the patient. The utmost the medical man can tell is
■whether the patient is weaker or stronger at this visit than he was at
the last visit. I should therefore say that incomparably the most
important office of the nurse, after she has taken care of the patient's

WHAT FOOD ? 43

air, is to take care to observe the eftect of his food, and report it to
the medical attendant.

It is quite incalculable the good that would certainly come from
such sound and close observation in this almost neglected branch ot
nursing, or the help it would give to the medical man.

A great deal too much against tea* is said by wise people, and a Tee and coffee
great deal too much of tea is given to the sick by foolish people.
AYhen you see the natural and almost universal craving in English
sick for their " tea," you cannot but feel that nature knows what she
is about. But a little tea or coffee restores them quite as much as
a great deal, and a great deal of tea and especially of coffee impairs
the little power of digestion they have. Yet a nurse because she
sees how one or two cups of tea or coffee restores her patient, thinks
that three or four cups will do twice as much. This is not the case
at all ; it is however certain that there is nothing yet discovered
which is a substitute to the English patient for his cup of tea ; he
can take it when he can take nothing else, and he often can't take
anything else if he has it not. I should be very glad if any of the
abusers of tea wouM point out what to give to an English patient
after a sleepless night, instead of tea. If you give it at 5 or 6 o'clock
in the morning, he may even sometimes fall asleep after it, and get
perhaps his only two or three hours' sleep during the twentj^four.
At the same time you never should give tea or coffee to the sick,
as a rule, after 5 o'clock in the afternoon. Sleeplessness in the early
night is from excitement generally and is increased by tea or coffee ;
sleeplessness which continues to the ear^y morning is from exhaustion
often, and is relieved by tea. The only English patients I have evei
known refuse tea, have been typhus cases, and the first sign of their
getting better was their craving again for tea. In general, the dry
and dirty tongue always prefers tea to coffee, and will quite decline
milk, unless with tea. Coffee is a better restorative than tea, but a

* It is made a frequent recommendation to persons about to incur great ex-
haustion, either from the nature of th-a service or from their bein^ not in a state
fit for it, to eat a piece of bread before they go. I wish the recommenders would
themselves try the experiment of substituting a piece of bread for a cup of tea or
coffee or beef tea as a refresher. They would find it a very poor comfort. When
soldiers have to set out fasting on fatiguing duty, when nurses have to go
fasting in to their patients, it is a hot restorative they want, and ought to have,
before they go, not a cold bit of bread. And dreadful have been the consequences
of neglecting thi.s. If they can take a bit of bread with the hot cup of tea, so
much the better, but not instead of it. The fact that there is more nourishment
in bread than in almost anything else has probably induced the mistake. That
it is a fatal mistake there is no doubt. It seems, though very little is known on
the subject, that what "assimilates" itself directly and with the least trouble
of digestion with the human body is the best for the above circumstances. I3rcad
requires two or three processes of assimilation, before it becomes like the human
body.

The almost universal testimony of English men and women who have un-
dergone great fatigue, such as riding long journeys without stopping, or sitting
up for several nights in succession, is that they could do it best upon an occas'oi.il
cap of tea— and nothing else.

Let experience, uol theory, decide upon this as upon all other ihingis.

45! XOTES ON NUESINd.

greater imprdrer of tlie digestion. Let the patient's taste decide.
You will say that, in cases of great thirst, the patient's craving
decides that it will drink a great deal of tea, and that you cannot help
it. But in these cases be sure that the patient requires diluents for
quite other purposes than quenching the thirst ; he wants a great
deal of some drink, not only of tea, and the doctor will order what
he is to have, barley water or lemonade, or soda water and milk, as
the case may be.

Lehmaun, quoted by Dr. Christison, says that, among the well
and active " the infusion of 1 oz. of roasted coffee daily will diminish
the waste " going on in the body " by one-fourth," andDr. Christison
adds that tea has the same property. Now this is actual experiment.
Lehmann weighs the man and finds the fact from his weight. It is
not deduced from any "analysis" of food. All experience among
the sick shows the same thing.*

Cocoa. Cocoa is often recommended to the sick in lieu of tea or cofi'ee.

But independently of the fact thdt English sick very generally dislike
cocoa, it has quite a different effect from tea or coffee. It is an oily
starchy nut having no restorative power at all, but simply increasing
fat. It is pure mockery of the sick, therefore, to call it a substitute
for tea. For any renovating stimulus it has, you might just as well
offer them chesnuts instead of tea.

^ "'^ An almost universal error among nurses is in the bulk of the food

and especially the drinks they offer to their patients. Suppose a
patient ordered 4 oz. brandy during the day, how is he to take this if
you make it into four pints with diluting it ? The same with tea and
beef tea, with arrowroot, milk, &c. You have not increased the
]iourishment, you have not increased the renovating power of these
articles, by increasing their bulk, — you have very likely diminished both
by giving fhe patient's digestion more to do, and most likely of all,
the patient will leave half of what he has been ordered to take,
because he cannot swallow the bulk with which you have been pleased
to invest it. It requires very nice observation and care (and meets
with hardly any) to determine what will not be too thick or strong
for the patient to take, while giving him no more than the bulk
which he is able to swallow.

* In making coffee, it is absolutely necessary to buy it in the berry and grind
it at home. Otherwise you may reckon upon its containing a certain amount of
chicory, at least. This is not a question of the taste- or of the wholesomeness of
chicory. It is that chicory has nothing at all of the properties for which you
give coffee. And therefore you may ag- -well not give it.

Again, all laundresses, mistresses of dairy-farms, head nurses (I speak of the
good old sort only— women who unite a good deal of hard manual labour with
the head work necessary for arranging the day's business, so that none of it shall
tread upon the heels of something else) set great value, I have observed, upon
having a high-priced tea. This is called extravagant. But these women are
'• extravagant" in nothing else. And they are right in this. Real tea-leaf tea alone
contains the restorative they want ; which is nol to be found in sloe-leaf tea.

The mistresses of houses, who cannot even go over their own house once
a-day, are incapable of judging for thes^ women. For they are incapable them-
selves, to all appearance, of the spirit of arrangement (no small task) necessaij
for managing a large ward or dairy.

BED AND BEDDING. 45

YIII. BED AND BEDDING.

A few words upon bedsteads and bedding ; and principally as Feverishness
regards patients who are entirely, or almost entirely, confined to bed. a symptom of

Feverishness is generally supposed to be a symptom of fever— bedding.
in nine cases out of ten it is a symptom of bedding.* The patient
has had re-introduced into the body the emanations from himself
which day after day and week after week saturate his unaired bed-
ding. How can it be otherwise ? Look at the ordinary bed in which
a patient lies.

If I were looking out for an example in order to show what not LTncleanliness
to do, I should take the specimen of an ordinary bed in a private oi ordinar>'
house : a wooden bedstead, two or even three mattresses piled up to betiding,
above the height of a table ; a vallance attached to the frame —
nothing but a miracle could ever thoroughly dry or air such a bed
and bedding. The patient must inevitably alternate between cold
damp after his bed is made, and warm damp before, both saturated
with organic matter,t and this from the time the mattresses are put
under him till the time they are picked to pieces, if this is ever done.

If you consider that an adult in health exhales by the lungs and Air your dirty
skin in the twentj'-four hours three pints at least of moisture, loaded sheets, not
with organic matter ready to enter into putrefaction ; that in sickness ^^h' your
the quantity is often greatly increased, the quality is always more ^'^^'^ °^^^^"
noxious — ^^just ask yourself next where does all this moisture go to?
Chiefly into the bedding, because it cannot go anywliere else. And it
stays there ; because, except perhaps a weekly change of sheets,
scarcely any other airing is attempted. A nurse will be careful to
fidgetiness about airing the clean sheets from clean damp, but airinf^
the dirty sheets from noxious damp will never even occur to her.
Besides this, the most dangerous effluvia we know of are from the
excreta of the sick — these are placed, at least temporarily, where they
must throw their effluvia into the under side of the bed, and the
space under the bed is never aired ; it cannot be, with our arrange-
ments. Must not such a bed be always saturated, and be always
the means of re-introducing into the system of the unfortunate
patient wlio lies in it, that excrementitious matter to eliminate which
iiorn the body nature had expressly appointed the disease ?

My heart always sinks within me when I hear the good house-
wife, of every class, say, " I assure you the bed has been well slept

* I once told a " very good nurse" that the way in Trhich her patient's roora Nurses often
was kept was quite enough to account for his sleeplessness: and she answered do not think
quite good-humnuredly she was not at all surprised at it— as if the state oi the the sick room
room were, like the state of the weather, entirely out of her power. Now in what anv business of
sense was this woman to be called a " nurse]" theirs, but

+ For the same reason if, after washing a patient, you must put the same only the sick.
night-dress on iiim again, always give it a preliminary warm at the fire. 'J he
night-gown he has Avorn must be, to a ceHain extent, damp. It has now got
cold from having been off him for a few minutes. The fire will dry and at the
same lime air it. This is much more important than with clean things.

46 NOTES ON NUESING.

in," and I can onl_y hope it is not true. "What ? is the bed already
saturated with somebody else's damp before my patient comes to
exhale into it his own damp ? Has it not had a single chance to be
aired ? No, not one. " It has been slept in every niglit."
Iron spring The only way of really nursing a real patient is to have an iron

bedstead the bedstead, with rheocline springs, which are permeable by the air up
best. to the very mattress (no vallance, of course), the mattress to be a

thin hair one ; the bed to be not above 3| feet wide. If the patient
Comfort and be entirely confined to his bed, there should be two such bedsteads ;
cleanliness of each bed to be " made" with mattress, sheets, blankets, &c., complete
two beds. — tiie patient to ])ass twelve hours in each bed ; on no account to

carry his sheets with him. The whole of the bedding to be hung up
to air for each intermediate twelve hours. Of course there are many
cases where this cannot be done at all — many more where only an
approach to it can be made. 1 am indicating the ideal of nursing,
and what I have actually had done. But about the kind of bedstead
there can be no doubt, whether there be one or two provided.
Bed not to be There is a prejudice in favour of a wide bed — I believe it to be

too wide, a prejudice. All the refreshment of moving a patient from one side

to the other of his bed is far more effectually secured by putting
him into a fresh bed ; and a patient who is really very ill does not
stray far in bed. But it is said there is no room to put a tray down
on a narrow bed. No good nurse will ever put a tray on a bed at all.
If the patient can turn on his side, he will eat more comfortably
from a bed-side table ; and on no account whatever should a bed
ever be higher than a sofa. Otherwise the patient feels himself
" out of humanity's reach"; he can get at nothing for himself: he can
move nothing for himself. If the patient cannot turn, a table over
the bed is a better thing. I need hardly say that a patient's bed
should never have its side against the wall. The nurse must be
able to get easily to both sides the bed, and to reach easily every
part of the patient without stretching — a thing impossible if the bed
be either too wide or too high.
Bed not to be- When I see a patient in a room nine or ten feet high upon a bed
too high. between four and five feet high, with his head, when he is sitting up

in bed, actually within two or three feet of the ceiling, I ask myself,
is this expressly planned to produce that peculiarly distressing
feeling common to the sick, viz., as if the walls and ceiling were
closing in upon them, and they becoming sandwiches between floor
and ceiling, which imagination is not, indeed, here so far from the
truth ? If, over and above this, the window stops short of the
ceiling, then the patien-'s head- may literally be raised above the
stratum of fresh air, even when the window is open. Can human per-
versity any farther go, in unmaking the process of restoration w^iich
Ood has made ? The fact is, that the heads of sleepers or of sick
should never be higher than the throat of the chimney, which ensures
Clieir being in the current of best air. And we will not suppose it
i^ossible that you have closed your chimney with a chimney-board.

If a bed is higher than a sofa, the difference of the fatigue of
g-etting in and out of bed will just make the difierence, very often, to

LIGHT. 47

the patient (who can get in and out of bed at all) of being able to
take a few minutes' exercise, either in the open air or in another
room. It is so very odd that people never think of this, or of how
many more times a patient who is in bed for the twenty-four hours
is obliged to get in and out of bed than they are, who only, it is to be
hoped, get into bed once and out of bed once during the twenty-four
hours.

A patient's bed should always be in the lightest spot in the room ; Nor in a dark
and he should be able to see out of window. place.

I need scarcely say that the old four-post bed with curtains is Nor a four
utterly inadmissible, whether for sick or well. Hospital bedsteads poster with
are in many respects very much less objectionable than private <^"^t^i^s.
ones.

There is reason to believe that not a few of the apparently unac- Scrofula often
countable cases of scrofula among children proceed from the habit ^ result of dis-
of sleeping with the head under the bed clothes, and so inhaling air F°^^V°ii
already breathed, which is farther contaminated by exhalations from
the skin. Patients are sometimes given to- a similar habit, and it
often happens that the bed clothes are so disposed that the patient
must necessarily breathe air more or less contaminated by exhala-
tions from his skin. A good nurse will be careful to attend to this.
It is an important part, so to speak, of ventilation.

It may be worth while to remark, that where there is any danger Bed sores,
of bed-sores a blanket should never be placed under the patient. It
retains damp and acts like a poultice.

N'ever use anything but light "Witney blankets as bed covering Heavy and im-
for the sick. The heavy cotton impervious counterpane is bad, for pervious bed-
the very reason that it keeps in the emanations from the sick person, clothes,
while the blanket allows them to pass through. Weak patients are
invariably distressed by a great weight of bed-clothes, which often
prevents their getting any sound sleep whatever.

Note. — One word' about pillowsi Every weak patient, be his illness what it
may, suffers more or less from difliculty in breathing. To take the we ght of the
body off the poor chest, which is hardly up to its work as it is, ought therefore to
be the object of the nurse in arranging his pillows. Now what does she do and
what are the consequences'? She piles the pillows one a-top of the other like a
Avail of bricks. The head is thrown upon the chest. And the shoulders are
pushed forward, so as not to allow the lungs room to expand. The pillows, in
fa?t, lean upon the patient, not the patient upon the pillows. It is impossible to
give a rule for this, because it must vary with the figure of the patient. And tall
patients suffer much more than short ones, because of the drag of the- long limbs
upon the waist. But the object is to support, with the pilloAvs, the back helow
the breathing apparatus, to allow the shoulders room to fall back, and' to support
the head, without throwing it forward The suffering of dying patients is jra-
mensely increased by neglect of these points. And many an invalid, tco wrnk
to drag about his pillows himself, slips his book or anything at hand behind the
lower part of his back to support it.

IX. LIGHT.

It is the unqualified result of all my experience with the sick, Light essential

that second only to their need of fresh air is their need of light ; *° Y^^ health
•' ° and recovery.

48 NOTES ON NURSING.

that, after a close room, what hurts them most is a dark room.
And that it is not only light hut direct sun-light they want. I had
rather have the power of carrying my patient about after the sun,
according to the aspect of the rooms, if circumstances permit, than
let him linger in a room when the sun is off. People think the effect
is upon the spirits only. This is by no means the case. The sun is
not only a painter but a sculptor. You admit that he does the
photograph. Without going into any scientific exposition we must
admit that light has quite as real and tangible effects upon the
human body. But this is not all. Who has not observed the
purifying effect of light, and especially of direct sunliglit, upon the
air of a room ? Here is an observation within everybody's expe-
rience. Go into a room where the shutters are always shut, (in a
sick room or a bedroom there should never be shutters shut), and
though the room be uninhabited, though the air has never been
polluted by the breathing of human beings, you will observe a close,
musty smell of corrupt air, of air i. e. unpurified by the effect of the
sun's rays. The mustiness of dark rooms and corners, indeed, is
proverbial. The cheerfulness of a room, the usefulness of light in
treating disease is all-important.
Aspect, view, ^ very high authority in hospital construction has said that

and sunlight people do not enough consider the difference between wards and
matters of first dormitories in planning their buildings. But I go farther, and say,
importance ^]^^^ healthy people never remember the difference between bed-
rooms and sick-rooms, in making arrangements for the sick. To a
sleeper in health it does not signify what the view is from his bed.
He ought never to be in it excepting when asleep, and at night.
Aspect does not very much signify either (provided the sun reach
his bed-room some time in every day, to purify the air), because he
ought never to be in his bed-room except during the hours when
there is no sun. But the case is exactly reversed with the sick, even
should they be as many hours out of their beds as you are in yours,
which probably they are not. Therefore, that they should be able,
without raising themselves or turning in bed, to see out of window
from their beds, to see sky and sun-light at least, if you can show
them nothing else, I assert to be, if not of the very first importance
for recovery, at least something very near it. And you should there-
fore look to the position of the beds of your sick one of the very first
things. If they can see out of two windows instead of one, so much
the better. Again, the morning sun and the mid-day sun — the hours
when they are quite certain not to be up, are of more importance to
them, if a choice must be made, than the afternoon sun. Perhaps
you can take them out of bed in the afternoon and set them by the
window, where they can see the sun. But the best rule is, if
possible, to give them direct sun-light from the moment he rises till
the moment he sets.

Another great difference between the hed-voom and the sick-room.
is, that the sleeper has a very large balance of fresh air to begin with,
when he begins the night, if his room has been open all day as it
ought to be ; the sick man has not, because all dav he has beeu

CLEANLINESS OF ROOMS AND WALLS. 49

breathing the air in the same room, and dirtying it by the emanations
from himself. Far more care is therefore necessary to keep up a
constant change of air in the sick room.

It is hardly necessary to add that there are acute cases (particu-
larly a few ophthalmic cases, and diseases where the eye is morbidly
sensitive), where a subdued light is necessary. But a dark nortli
room is inadmissible even for these. You can always moderate the
light by blinds and curtains.

Heavy, thick, dark window or bed curtains should^ however,
hardly ever be used for any kind of sick in this country. A light
white curtain at the head of the bed is, in general, all tliat is neces-
sary, and a green blind to the window, to be drawn down only when
necessary <,

One of the greatest observers of human things (not physiological) , ^Vithout sun-
says, in another language, " Where there is sun there is thought." light, we de-
All physiology goes to confirm this. Where is the shady side of generate bodj
deep valleys, there is cretinism. Where are cellars and the un- J^m^i-
sunned sides of narrow streets, there is the degeneracy and weakli-
ness of the human race — mind and body equally degenerating. Put
the pale withering plant and human being into the sun, and, if not
too far gone, each will recover health and spirit.

It is a curious thing to observe how almost all patients lie with Almost all
their faces turned to the light, exactly as plants always make their patients lie
way towards the light ; a patient will even complain that it gives J^^^^ ^}^^l^
him pain "lying on that side." "Then why do you lie on that }■ ^^^J^ ^
side?" He does not know, — but we do. It is because it is the side '^
towards the window. A fashionable physician has recently published
in a government report that he always turns his patients' faces from
the light. Yes, but nature is stronger than fashionable physicians, and
depend upon it she turns the faces back and toipards such light as
she can get. "Walk through the wards of a hospital, remember the
bed sides of private patients you have seen, and count how many sick
you ever saw lying with their faces towards the wall.

X. CLEANLINESS OF EOOMS AND WALLS

It cannot be necessary to tell a nurse that she should be clean Cleanliness of
or that she should keep her patient clean, — seeing that the greater carpets and
part of nursing consists in preserving cleanliness. No ventilation ''^^^ ^^^'
can freshen a room or ward where the most scrupulous cleanliness is
not observed. Unless the wind be blowing through the windows at
the rate of twenty miles an hour, dusty carpets, dirty wainscots,
musty curtains and furniture, will infiUibly produce a close smell.
I have lived in a large and expensively furnished London house,
where the only constant inmate in two very lofty rooms, with
opposite windows, was myself, and yet, owing to the abovementioned
dirty ci-rcum stances, no opening of windows could ever keep those

E

50

KOTES ON NUESINO.

Dust never re-
moved now.

Floors.

Papered,
plastered, oil-
[)amted walls.

diiditd.

ow a roon) is

rooms free from closeness ; but the carpet and curtains having
been turned out of the rooms altogether, they became instantly as
fresh as could be wished. It is pure nonsense to say that in
London a room cannot be kept clean. Many of our hospitals show
the exact reverse.

But no particle of dust is ever or can ever be removed or really
got rid of by the present system of dusting. Dusting in these days
means nothing but flapping the dust from one part of a room on to
another with doors and windows closed. What you do it for I
cannot think. You had much better leave the dust alone, if you
are not going to take it away altogether. For from the time a room
begins to be a room up to the time when it ceases to be one, no one
atom of dust ever actually leaves its precincts. Tidying a room
means nothing now but removing a thing from one place, which it
has kept clean for itself, on to another and a dirtier one.* Flapping
by way of cleaning is only admissible in the case of pictures, or
anything made of paper. The only way I know to remove dust, the
plague of all lovers of fresh air, is to wipe everything with a damp
cloth. And all furniture ought to be so made as that it may be
wiped with a damp cloth without injury to itself, and so polished as
that it may be damped without injury to others. To dust, as it
is now practised, truly means to distribute dust more equally over a
room.

As to floors, the only really clean floor I know is the Berlin
lackered floor, which is wet rubbed and dry rubbed every morning
to remove the dust. The French parquet is always more or less
dusty, although infinitely superior in point of cleanliness and
healthiness to our absorbent floor.

For a sick room, a carpet is perhaps the worst expedient which
could by any possibility have been invented. If you must have a
carpet, the only safety is to take it up two or three times a year,
instead of once. A dirty carpet literally infects the room. And if
vou consider the enormous quantity of organic matter from the feet
"of people coming in, which must saturate it, this is by no means
surprising.

As for walls, the worst is the papered wall ; the next worst is
plaster. But the plaster can be redeemed by frequent lime-washing;
the paper requires frequent renewing. A glazed paper gets rid of a

If you like to clean your furniture by laying out your clean clothes upon
your dirty chairs or sofa, tlais is one Avav certainly of doing it. Having witnessed
the morning process called "tidying the room," for many years, and with ever-
increasing astonishment, 1 can describe wnat it is. From the chairs, tables, oi
sofa, upon which the " things" have lain during the night, and which are there-
fore comparatively clean from dust or blacks, the poor " things' having "caught"
it, they are removed to other chairs, tables, sofas, upon which you could
write your name with your finger in the dust or blacks. The other side of the
" things" is therefore now evenly dirtied or dusted. The housemaid then flaps
every thing, or some things, not out of her reach, with a thing called a duster—'
tte dust flies up, then re-settles more equally than it lay before the operatiou
"i'lie room has now been " put to rightcs,"

CLEANLINESS OF BOOMS AND WALLS. 61

good deal of the danger. But the ordinary bed-room paper is all
that it ought not to be.*

The close connection between ventilation and cleanliness isr
shown in this. An ordinary light paper will last clean much longer
if there is an Arnott's ventilator in the chimney than it otherwise
would.

The best wall now extant is oil paint. Prom this you can wash
the animal exuviae. t

These are what make a room mu&ty.

The best wall for a sick-room or ward that could be made is Best kind of
pure white non-absorbent cement or glass, or glazed tiles, if they wall for a
were made sightly enough. sick room.

Air can be soiled just like water. If you blow into water
you will soil it with the animal matter from your breath. So it is
with air. Air is always soiled in a room where walls and carpets
are saturated with animal exhalations.

Want of cleanliness, then, in rooms and wards, which you have
to guard against, may arise in three ways.

1. Dirty air coming in from without, soiled by sewer emanations. Dirty air from
the evaporation from dirty streets, smoke, bits of unburnt fuel, bits- without.

of straw, bits of horse dung.

If people would but cover the outside w^alls of their houses with Best kind of
plain or encaustic tiles, what an incalculable imjDrovement would wall lor a
there be in light, cleanliness, dryness, warmth, and consequently house,
economy. The play of a fire-engine would then effectually wash the
outside of a house. This kind of walling would stand next to paving
in improving the health of towns.

2. Dirty air coming from within, from dust, which you often Dirty air from
displace, but never remove. And this recalls w-hat ought to be a within,

sine qua non. Have as few ledges in your room or ward as possible.
And under no pretence have any ledge whatever out of sight. Dust
accumulates there, and will never be wiped off. This is a certaiu
way to soil the air. Besides this, the animal exhalations from your
inmates saturate your furniture. And if you never clean your
furniture properly, how can your rooms or wards be anything but
musty ? Ventilate as you please, the rooms will never be sweet.
Besides this, there is a constant degradation, as it is called, taking
place from everything except polished or glazed articles — ^. y., in
colouring certain green papers arsenic is used. Now in the very
dust even, which is lying about in rooms hung with this kind of
green paper, arsenic has been distinctly detected. You see your
dust is anything but harmless ; yet you will let such dust lie about
your ledges for months, your rooms for ever.

* I am sure that a person who has accustomed her senses to compare atmo- ^J^J^l "h' '"
spheres proper and improper, for the sick and for children, could tell, blindfold, pllpej-eji roo„^g
the difference of the air in old painted and in old papered rooms, center Is paribus, ^^^^j^^ distin-
rhe latter will always be musty, even with all the windows open. _ guishable.

t If you like to wipe your dirty door, or some portion of your dirty wall, by jj^^^ ^^ ^^^^^
nanging up your clean gown or shawl against it on a peg, this is one way cer- your wall cjean
tainly, and the most usual way, ami generally the only Avay of cleaning either door at the expence
or wall in a bed-room. ' of your clothes.

e2

52

KOTES ON NUESI>'G.

Dirty air from
the carpet.

"Remedies.

Again, the fire fills the room with coal-dust.

3. Dirty air coming from the carpet. Above all, take care of the
carpets, that the animal dirt left there by the feet of visitors
does not stay there. Floors, unless the grain is filled up and
polished, are just as bad. The smell from the floor of a school-room
or ward, when any moisture brings out the organic matter by whicii
it is saturated, might alone be enough to warn us of the mischief
that is going on.

The outer air, then, can only be kept clean by sanitary improve-
ments, and by consuming smoke. The expense in soap, which this
single improvement would save, is quite incalculable.

The inside air can only be kept clean by excessi\'e care in the
ways mentioned above — to rid the walls, carpets, furniture, ledges,
&c., of the organic matter and dust — dust consisting: greatly of this
organic matter — with which they become saturated, and which is
what really makes the room musty.

Without cleanliness,, you cannot have all the eftect of ventilation ;
without ventilation, you can have no thorough cleanliness.

A^'ery few people, be they of what class they may, have any idea
of the exquisite cleanliness required in th@ sick room. For much of
what I have said applies less to the hospital than to the private sick-
room. The smoky chimney, the dusty furniture, the utensils
emptied but once a day, often keep the air of the sick constantly
dirty in the best private houses.

The well have a curious habit of forgetting that what is to them
but a trifling inconvenience, to be patiently " put up " witli, is to
the sick a source of suff*ering, delaying recovery, if not actually
hastening death. The well are scarcely ever more than eight hours,
at most, in the same room. Some change they can always make, if
only for a few minutes. Even during the supposed eight hours, they
can change their posture or their position in the room. But the
sick man, who never leaves his bed, who cannot change by any
movement of his own hi^ air, or his light, or his warmth; who cannot
obtain quiet, or get out of the smoke, or the smell, or the dust ; he is
really poisoned or depressed by what is to you the merest trifle.

" What can't be cured must be endured," is the very worst and
most dangerous maxim for a nurse which ever was made. Patience
and resignation in her are but other words for carelessnesa or
indifference — contemptible, if in regard to herself; culpable, if in
regard to her sick.

XL PEESONAL CLEANLINESS.

Poisoning by
the skin.

In almost all diseases, the function of the skin is, more or less,
disordered ; and in many most important diseases nature relieves
herself almost entirely by the skin. This is particularly the case
with children. But the excretion, which comes from the skin, is left
there, unless removed by washing or by the clothes. Every nurse

PEESONAL CLEANLINESS. 53

should keep this fact eoiistaiitly in mind, — for, if slie allow Ler sick
to remain unwashed, or their clothing to remain on them after being
saturated with perspiration or other excretion, she is interfering
ijijuriously with the natural processes of health just as eflectuallj as
it' she were to give the patient a dose of slow poison by the mouth.
Poisoning by the skin is no less certain than poisoning by the mouth
— only it is slower in its operation.

The amount of relief and comfort experienced by sick after the Ventilation
skin has been carefully washed and dried, is one of the commonest aiidskin-clcan-
observations made at a sick bed. But it must not be forgotten that ^u^ess. equally
the comfort and relief so obtained are not all. They are, in fact, ^''''^'^ ^^ '
nothing more than a sign that the vital powers have been relieved by
removing sometliing that was oppressing them. The nurse, there-
fore, must never put off attending to the personal cleanliness of her
patient under the plea that ail that is to be gained is a little relief,
which can be quite as well given later.

In all well-regulated hospitals this ought to be, and generally is,
attended to. But it is very generally neglected with private sick.

Just as it is necessary to renew the air round a sick person
frequently, to carry off morbid effluvia from the lungs and skin, by
maintaining free ventilation, so is it necessary to keep the pores of
the skin free from all obstructing excretions. The object, both of
ventilation and of skin-cleanliness, is pretty much the same, — to wit,
removing noxious matter from the system as rapidly as possible.

Care should be taken in all these operations of sponging, washing,
and cleansing the skin, not to expose too great a surface at once, so
as to check the perspiration, which would renew the evil in another
form.

The various ways of washing the sick need not here be specified,
— the less so as the doctors ought to say which is to be used.

In several forms of diarrheea, dysentery, &c., where the skin is
hard and harsh, the relief afforded by washing with a great deal of
soft soap is incalculable. In other cases, sponging with tepid soap
and water, then with tepid water and drying with a hot towel will be
ordered.

Every luirse ought to be careful to wash her hands very fre-
quently during the day. If her face too, so much the better.

One word as to cleanliness merely as cleanliness.

Compare the dirtiness of the water in which you have washed Steaminc: and
when it is cold without soap, cold with soap, hot with soap. You rubbing ihe
will find the first has hardly removed any dirt at all, the second a ^^^^•
little more, the third a great deal more. But hold your hand over a
cup of hot water for a minute or two, and then by merely rubbing
with the finger, you will bring off" flakes of dirt or dirty skin. After
a vapour bath you may peel your whole self clean in this way. "What
I mean is, that by simply washing or sponging with water you do not
really clean your skin. Take a rough towel, dip one corner in very
hot water, — ^^if a little spirit be added to it it will be more effectual, —
and then rub as if you were rubbing the towel into your skin
with your fingers. The black flakes which will come off' will convince

54 NOTES OX NUESING.

you that you were not clean before, however much soap and water
you have used. Tliese flakes are what require removing. And you
can really keep yourself cleaner with a tumbler of hot water and a
rough towel and rubbing, than with a whole apparatus of bath and
soap and sponge, without rubbing. It is quite nonsense to say that
anybody need be dirty. Patients have been kept as clean bv these
means on a long voyage, when a basin full of water could not be
afl^brded, and when they could not be moved out of their berths, as
if all the appurtenances of home had been at hand.

Washing, however, with a large quantity of water has quite other
effects than those of mere cleanliness. The skin absorbs the water
and becomes softer and more perspirable. To wash with soap and
soft water is, therefore, desirable from other points of view than that
ef cleanliness.

XII. CHATTEEING HOPES AND ADVICES.

Advising the The sick man to his advisers.

^^^'^^ " My advisers ! Their name is legion. * * *

Somehow or other, it seems a provision of the universal destinies,
that every man, woman, and child should consider him, her, or it.self
privileged especially to advise me. Why ? That is precisely what
I want to know." And this is what I have to say to them. I have
been advised to go to every place extant in and out of England — to
take every kind of exercise by every kind of cart, carriage — yes,
and even swing (!) and dumb-bell (!) in existence; to imbibe every
different kind of stnnulus that ever has been invented. And this
when those best fitted to know, viz , medical men, after long and
close attendance, had declared any journey out of the question, had
prohibited any kind of motion whatever, had closely laid down the
diet and drink. What would my advisers say, were they the medical
attendants, and I the patient left their advice, and took the casual
adviser's? But the singularity in Legion's mind is this: it never
occurs to him that everybody else is doing the same thing, and that
I the patient musi. perforce say, in sheer self-defence, like Eosalind,
" I could not do with all."

Chattering "" Chattering Hopes" may seem an odd heading. But I really

hopes the bane Relieve there is scarcely a greater worry which invalids have to endure
le SIC '. than the incurable hopes of their friends. There is no one practice
against which I can speak more strongly from actual personal expe-
rience, wide and long, of its effects during sickness observed both upoa
others and upon myself I would appeal most seriously to all friends,
visitors, and attendants of the sick to leave off this practice of
attempting to " cheer " the sick by making light of their danger and
by exaggerating their probabilities of recovery.

Ear more now than formerly does the medical attendant tell the
truth to the sick who are really desirous to liear it about their owl:
state.

ClIATTERIXG HOPES A:SD ADTICES. 55

How intense is the folly, then, to say the least of it, of the friend,
be he even a medical man, who thinks that his opinion, given after a
cursory observation, will weigh with the patient, against the opinion
of the medical attendant, given, perhaps, after years of observation,
after using every help to diagnosis afforded b)'' the stethoscope, the
examination of pulse, tongue, &c. ; and certainly after much more
observation than the friend can possibly have had.

Supposing the patient to be possessed of common sense, — how
can the "favourable" opinion, if it is to be called an opinion at all,
of the casual visitor " cheer " him, — when different from that of the
experienced attendant ? Unquestionably the latter may, and often
does, turn out to be wrong. But which is most likely to be
wrong ?

The fact is, that the patient* is not "cheered" at all by these patient does
well-meaning, most tiresome friends. On the contrary, he is de- not want to
pressed and wearied. If, on the one hand, he exerts himself to tell talk of himself,
each successive member of this too numerous conspiracy, whose
name is legion, why he does not think as they do, — in what respect
he is worse, — what symptoms exist that they know nothing of, — he
is ftitigued instead of " cheered," and his attention is fixed upon
himself. In general, patients who are really ill, do not want to talk
about themselves. Hypochondriacs do, but again I say we are not
on the subject of hypochondriacs.

If, on the otlier hand, and which is much more frequently the case. Absurd conso-
the patient says nothing, but the Shakespearian "Oh!" "Ah!" " Go lations put
to!" and " In good sooth !" in order to escape from the conversation torth for the
about himself the sooner, he is depressed by want of sympathy. He ^.^^^^^ ^^ ^^^^
feels isolated in the midst of friends. He feels what a convenience it
would be, if there were any single person to whom he could speak
simply and openly, without pulling the string upon himself of this

* There are, of course cases, as in first confinements, when an assurance from Absurd statis-
tlie doctor or experienced nurse to tlie frightened suffering woman that there is tical compari-
nothing unusual in her case, that she has nothing to fear but a few hours' pain, sons made in
may cheer her most effectually. This is advice of quite another order. It is the common con-
advice of experience to utter inexperience. But the advice we have been refer- versation by .
ring to is the advice of inexperience to bitter experience ; and, in general, the most sen-
amounts to nothing more than this, that yozi think / shall recover from consump- sible people
tion, because somebody knows somebody somewhere who has recovered from for the beneft
fever. of the sick.

1 have heard a doctor condemned whose patient did not, alas ! recover, be-
cause another doctor's patient of a (liferent sex, of a different age, recovered
from a different disease, in a cUfferent place. Yes, this is really true. If people
(jrho make these comparisons did but know (only they do not care to know), the
care and preciseness with which such comparisons require to be made, (and are
made), in order to be of any value whatever, they would spare their tongues. In
comparing the deaths of one hospital with those of another, any statistics are
justly considered absolutely valuele>s which do not give the ages, the sexes, and
the diseases of all the cases. It does not seem necessary to mention this. It does
not seem necessary to say that there can be no comparison between old men witli
dropsies and young women with consumptions. Yet the cleverest men and the
cleverest women are often heard making such comparisons, ignoring entirely sex,
age. disease, place — iu fact, all the conditions esscniial to i\\Q question. It is the
merest gossip.

56 NOTES ox NUESING.

shower-bath of silly hopes and encouragements; to whom he could
express his wishes Jind directions without that person persistinrij in
saying " I hope that it will please God yet to give you twenty
years," or, " Tou have a long life of activity before you." How
often we see at the end of biographies or of cases recorded in medical
papers, " after a long illness A. died rather suddenly," or, " unex-
pectedly both to himself and to others." " Unexpectedly " to others,
perhaps, who did not see, because they did not look ; but by no
means " unexpectedly to himself," as 1 feel entitled to believe, both
from the internal evidence in such stories, and from watching simJl^j
cases : there was every reason to expect that A. would die, and he
Imew it ; but he found it useless to insist upon his own knowledge
to his friends.

In these remarks I am alluding neither to acute cases xvhich
terminate rapidly nor to "nervous " cases.

By the first much interest in their own danger is very rarely felt.
In writings of fiction, whether novels or biographies, these death-beds
are generally depicted as almost seraphic in lucidity of intelligence.
Sadly large has been my experience in death-beds, and I can only
say that I have seldom or never seen such. Indifference, excepting
with regard to bodily suffering, or to some duty the dying man
desires to perform, is the far more usual state.

The " nervous case," on the other hand, delights in figuring to
himself and others a fictitious danger.

But the long chronic case, who knows too well himself, and who
has been told by his physician that he will never enter active life
again, who feels that every month he has to give up something he
could do the month before — oh ! spare such sufferers your chattering
hopes. Tou do not know how you worry and wearv them. Such
real sufferers cannot bear to talk of themselves, still less to hope
for what they cannot at all expect.

So also as to all the advice showered so profusely upon such sick,
to leave off some occupation, to try some other doctor, some other
house, climate, pill, powder, or specific; I say nothing of the incon-
sistency— for these advisers are sure to be the same persons who
exhorted the sick man not to believe his own doctor's prog-
nostics, because " doctors are always mistaken," but to believe some
other doctor, because "this doctor is always right." Sure also are
these advisers to be the persons to bring the sick man fresh occupa-
tion, while exhorting him to leave bis own.
WunJerfulpre- Wonderful is the face with which friends, lay and medical,
Gumption of will come in and worry the patient with recommendations to do
Lhe advisers of something or other, having just as little knowledge as to its being
* he sick. feasible, or even safe for him, as if they were to recommend a

man to take exercise, not knowing he had broken his leg. What
would the friend say, if lie were the medical attendant, and if
the patient, because some other friend had come in, because some-
body, anybody, nobody, had recommended something, anything,
nothing, were to disregard Ids orders, and take that other body's
recojumendation ? But people never think of this.

CHATTEEING HOPES AND ADVICES. ^7

A celebrated historical personage has related the conimou- Advisers the
places which, when on the eve of executing a remarkable reso- same now as
lution, were showered in nearly the same words by every one J^^^^^^J^
around successively for a period of six months. To these the
personage states that it was found least trouble always to reply
the same thing, viz., that it could not be supposed that such a
resolution had been taken without sufficient previous consideration.
To patients enduring every day for years from every friend or
acquaintance, either by letter or viva voce, some torment of this kind,
I would suggest the same answer. It would indeed be spared,
if such friends and acquaintances would but consider for one
moment, that it is probable the patient has heard such advice at
least fifty times before, and that, had it been practicable, it would
have been practised long ago. But of such consideration there
appears to be no chance. Strange, though true, that people should
be just the same in these things as they were a few hundred years
ago !

To me these commonplaces, leaving their smear upon the cheerful,
single-hearted, constant devotion to duty, which is so often seen in
the decline of such sufferers, recall the slimy trail left by the snail on
the sunny southern garden-wall loaded with fruit..

No mockery in the world is so hollow as the advice showered J^o^^^j^J>'°^
upon the sick. It is of no use for the sick, to say anything, for what . ^^ to sick,
the adviser wants is, not to know the truth about the state of the
patient, but to turn whatever the sick may say to the support of his
own argument, set forth, it must be repeated, without any inquiry
whatever into the patient's real condition. " But it would be im-
pertinent or indecent in me to make such an inquiry," says the
adviser. True ; and how much more impertinent is it to give your
advice when you can know nothing about the truth, and admit you
could not inquire into it.

To nurses I say — these are the visitors who do your patient
harm. When you hear him told: — 1. That he has nothing the
matter with him, and that he wants cheering. 2.. That he is com-
mitting suicide, and that he wants preventing. 3. That he is the
tool of somebody who makes use of him for a purpose. 4. That he
will listen to nobody, but is obstinately bent upon his own way ;
and 5. That he ought to be called to the sense of duty, and is flying
in the face of Providence ; — then know that your patient is receiving
all the injury that he can receive from a visitor.

How little the real sufferings of illness are known or understood.
How little does any one in good health fancy him or even Jier&elt into
f.he life of a sick person.

.Do, you who are about the sick or who visit the sick, try and give Means or
them pleasure, remember to tell them what will do so. How often in giving pica-
such visits the sick person has to do the whole conversation, exerting ^J^j.^
his own imagination and memory, while you would take the visitor, "
absorbed in his own anxieties, making no effort of memory or
imagination, for the sick person. " Oli !' my dear, I have so much to
think of, I really quite forgot to tell him that ;. besides, I thought he

58 NOTES OK NUESIXG.

would know it," says the visitor to another friend. How could " he
know it "? Depend upon it, the people who say this are really those
who have little " to think of." There are many burthened witli
business who alwavs manage to keep a pigeon-hole in their minds,
full of things to tell the " invalid."

I do not say, don't tell him your anxieties — T believe it is good
for him and good for you too ; but if you tell him what is anxious,
surely you can remember to tell him what is pleasant too.

A sick person does so enjoy hearing good news : — for instance, of
a love and courtship, while in progress to a good ending. If you tell
him only when the marriage takes place, he loses half the pleasure,
which God knows he has little enough of; and ten to one but you
have told him of some love-making with a bad ending.

A sick person also intensely enjoys hearing of any material good,
any positive or practical success of the right. He has so much of
books and fiction, of principles, and precepts, and theories ; do, in-
stead of advising him with advice he has heard at least fifty times
before, tell him of one benevolent act which has really succeeded
practically, — it is like a day's health to him.*

You have no idea what the craving of sick with undiminished
power of thinking, but little power of doing, is to hear of good
practical action, when they can no longer partake in it.

Do observe these things with the sick. Do remember how their
life is to them disappointed and incomplete. You see them lying
there with miserable disappointments, from which they can have no
escape but death, and you can't remember to tell them of what would
give them so much pleasure, or at least an hour's variety.

They don't want you to be lachrymose and whining with them,
they like you to be fresh and active and interested, but they cannot
bear absence of mind, and they are so tired of the advice and preach-
ing they receive from every body, no matter whom it is, they see.

There is no better society than babies and sick people for one
another. Of course you must manage this so that neither shall
6ufi<er from it, which is perfectly possible. It you think the " air of
the sick room" bad for the baby, why it is bad for the invalid too,
and, therefore, you will of course correct it for both. It freshens up
a sick person's whole mental atmosphere to see " the baby." And a
very young child, if unspoiled, will generally adapt itself wonderfully
to the ways of a sick person, if the time they spend together is not
too long.

If you knew how unreasonably sick people sufier from reasonable
causes of distress, you would take more pains about all these things.
An infant laid upon the sick bed will do the sick person, thus sufier-
ing, more good than all your logic. A piece of good news will do
the same. Perhaps you are afraid of " disturbing " him. You say
there is no comfort for his present cause of afiEliction. It is perfectly

* A small pet animal is often an excellent compan'on for the sick, for long
chronic cases especially. A pet bird in a cage is sometimes the ox\\\ pleasure of
an invalid confined for ^^ears to the same room. If he can feed and clean the
animal Mmself, he o.ugkt always to be encouraged io-do-SQ

OBSEEVATION OF THE SICK. 59

reasonable. The distinction is this, if he is oblif]jed to act, do not
''disturb" him with another subject of thought just yet; help him
to do what he wants to do : but, if he has done this, or if nothing
can be done, then "disturb" him by all means. You will relieve,
more effectually, unreasonable suiFering from reasonable causes by
telling him "the news," showing him "the baby," or giving him
something new to think of or to look at than by all the logic in the
world.

It has been very justly said that the sick are like children in this,
that there is wo proportion in events to them. Now it is your busi-
ness as their visitor to restore this right proportion for them — to
shew them what the rest of the world is doing. How can they find
it out otherwise ? You will find them far more open to conviction
than children in this. And you will find that their "unreasonable
intensity of suffering from unkindness, from want of sympathy, &c.,
will disappear with their freshened interest in the big world's events.
But then you must be able to give them real interests, not gossip.

Note. — There are two classes of patients which are imfortunately becoming Two new
more common every day, especially among women of the richer orders, to whom classes of
all these remarks are pre-eminently inapplicable. 1. Those who make health an patients pecu-
excuse for doing nothing, and at the same time allege that the being able to do liar to this
nothing is their only grief. 2. Those who have brought upon themselves ill- generation,
health by over pursuit of amusement, which they and their friends have most
unhappily called intellectual activity. I scarcely know a greater injury that can
be inflicted than the advice too often given to the first class '' to vegetate " —
or than the admiration too often bestowed on the latter class for "pluck."

XIII. OBSEEVATION OF THE SI€K.

There is no more silly or universal -question scarcely asked than What is the
this, " Is he better ?" Ask it of the medical attendant, if you please, use of the
But of whom else, if you wish for a real answer to your question, question, Is he
would you ask it ? Certainly not of the casual visitor ; certainly ^ ^'' '
not of the nurse, while the nurse's observation is so little exercised
as it is now. What you want are facts, not opinions — for who can
have any opinion of' any value as to whether the patient is better
or worse, excepting the constant medical attendant, or the really
observing nurse ?

The most important practical lesson that can be given to nurses
ib to teach them what to observe — how to observe — what symptoms
indicate improvement — what the reverse — which are of importance
— which are of none— whioh are the evidence of neglect — and of
what kind of neglect.

All this is what ought to make part, and an essential part, of the
training of every nurse. At present how few there are, either pro-
fessional or unprofessional, who really know at all whether any sick
person they may be with is better or worse.

The vagueness and looseness of the information one receives m
answer to that much abused question, "Is he better?^' would b©

60 ^-OTES ON NUESING.

ludicrous, if it were not paiiiful. The only sensible answer (iu th&
present state of knowledge about sicJniess) would be '' HovV cari I
know ? I cannot tell how he was wlien I war* not with hirn."

I can record but a very few specimens of the answers* which I
have heard made by friends and nurses, and accepted by physidaiis
and surgeons at the very bed-side of the patient, who could have
contradicted every word, but did not — sometimes from amiability,
often from shyness, oftenest from languor !

"How often have the bowels acted, nurse?" "Once, sir."
This generally means that the utensil has been emptied once, it
having been used perhaps seven or eight times.

" Do you think the patient is much weaker than he was six week :J
ago?" " Oh no, sir; you know it is very long since he has been up
and dressed, and he can get across the room now." This means that
the nurse has not observed that whereas six weeks ago he sat up
and occupied himself in bed, be now lies still doing nothing; that,
although he can "get across the room," he cannot stand for live
seconds.

Another patient who is eating well, recovering steadily, although
slowly, from fever, but cannot walk or stand, is represented to the
doctor as making no progress at all.

* It is a much more difficult thiiig to speak the truth than people commonly
imagine. There is the want of observation simple, and the want of observation
compound, compounded, that is, with the imaginative faculty. Both may eqaalij
'.ntend to speak the truth. The information of the first is simply defective. Tha'..
of the second is much more dangerous. The first gives, in answer to a question
asked about a thing that has been before his eyes perhaps for years, information
exceedingly imperfect, or says, he does not know. He has never observed. And
people simply think him stupid.

The second has observed just as little, but imagination immediately steps in,
and he describes the whole thing from imagination merely, being peifectly
convinced all the while that he has seen or heard it ; or he will repeat a whole
conversation, as if it were information which had been addressed to him ; whereas
it is merely what he has himself said to somebody else. This is the commonest
of all. These people do not even observe that they have not observed nor re-
member that they have forgotten.

Courts of justice seem to think that any body can speak "the whole truth
and nothing but the truth." if he doss but intend it. It requires many faculties
combined of observation and memory to speak " the whole truth " and to say
" nothing but the truth."

" I knows 1 fibs dreadful : but believe me. Miss, I never finds out I have
fibbed until they tells me so," was a remark actually made. It is also one of
much more extended application than most people have the least idea of.

Concurrence of testimony, which is so often adduced as final proof, may prove
nothing more, as is well known to those accustomed to deal with the unobservant
imaginative, than that one person has told his story a great many times.

I have heard thirteen persons ''concur" in declaring that a fourteenth, who
had never left his bed, went to a distant chapel every morning at seven o'clock.

I have heard persons in perfect good faith declare, that a man came to dine
every day at the house where they lived, who had never dined there once; that a
person had never taken the sacrament, by whose side they had twice at least
knelt at Communion ; that but one meal a day came out of a hospital kitchen,
which for six weeks they had seen provide from three to five and six meals a
day. Such instances might be multiplied ad infimtum if necessary.

OBSEEVATIOJi 0]? THE SICK. Gl

Questions, too, as asked now (but too generally) of or about Leading quet
patients, would obtain no information at all about them, even if the tions useless
person asked of had every information to give. The question is ^^ Diisleadiiig.
generally a leading question; and it is singular that people never
think what must be the answer to this question before they ask
it: for instance, " Has he had a good night?" Now, one patient
will think he has a bad night if he has not slept ten hours without
waking. Another does not think he has a bad night if he has had
intervals of dosing occasionally. The same answer has actually been
given as regarded two patients — one who had been entirely sleepless
for five times twenty-four hours, and died of it, and another who had
not slept the sleep of a regular night, without waking. AVliy cannot

the question be asked, How many hours' sleep has had ? and

at what hours of the night ?* " 1 have never closed my eyes all
night," an answer as frequently made when the speaker has had
several hours' sleep as when he has had none, would then be less
often said. Lies, intentional and unintentional, are much seldomer
told in answer to precise than to leading questions. i\nother
frequent error is to inquire whether one cause remains, and not
whether the effect which may be produced by a great many different
causes, not inquired after, remains. As when it is asked, whether
there was noise in the street last night ; and if there were not, the
patient is reported, without more ado, to have had a good night.
Patients are completely taken aback by these kinds of leading ques-
tions, and give only the exact amount of information asked for, even
when they know it to be completely misleading. The shyness of
patients is seldom allowed for.

How few there are who, by five or six pointed questions, can
elicit the whole case and get accurately to know and to bo able to
report wlie7'e the patient is.

I. knew a very clever physician, of large dispensary and hospital Means of
practice, who invariably began his examination of each patient with, obtaining
" Put your finger where you be bad." That man would never waste inaccurate
his time with collecting inaccurate information from nurse or patient. ^^ °^°^^ ^^^'
Leading questions always collect inaccurate information.

At a recent celebrated trial, the following leading question was
put successively to nine distinguished medical men. " Can you attri-
bute these symptoms to anything else but poison ?" And out of the
u-ne, eight answered " No !" without any qualification whatever. It
appeared, upon cross-examination : — 1. That none of them had ever
seen a case of the kind of poisoning supposed. 2. That none of them
had ever seen a case of the kind of disease to which the death, if not
to poison, was attributable. 3. That none of them were even aware

* This is important, because on this depends what the remedy will be. If a
patient sleeps two or three hours early in the night, and then does not sleep
again at all, ten to one it is not a narcotic he wants, but food or stimulus, or
perhaps only warmth. If on the other hand, he is restless and awake all night,
and is drowsy in the morning, he probably wants sedatives, either quiet, coolness,
\)r medicine, a lighter diet, or all four. Now the doctor should bc'toid this, cr
now can he judge what to give 1

62 NOTES ON NURSING,

of the main fact of the disease and condition to which the death
was attributable.

Surely nothing stronger can be adduced to prove what use leading
questions are of, and what they lead to.

I had rather not say how many instances I have known, where,
owing to this system of leading questions, the patient has died, and
the attendants have been actually unaware of the principal feature
of the case.
As to food It is useless to go through all the particulars, besides sleep, in

patient takes which people have a peculiar talent for gleaning inaccurate infor-
or does not mation. As to food, for instance, I often think that most common
<^ake. question. How is your appetite? can only be put because the ques-

tioner believes the questioned has really nothing the matter with him,
which is very often the case. But where there is, the remark holds
good which has been made about sleep. The same answer will often
be made as regards a patient who cannot take two ounces of solid
food per diem, and a patient who does not enjoy five meals a day as
much as usual.

Again, the question. How is your appetite ? is often put when
How is your digestion ? is the question meant. No doubt the two
things depend on one another. But they are quite different. Many
a patient can eat, if you can only "tempt his appetite." The fault
lies in your not having got him the thing that he fancies. But
many another patient does not care between grapes and turnips, —
everything is equally distasteful to him. He would try to eat any-
thing which would do him good \ but everything " makes him worse."
The fault here generally lies in the cooking. It is not his " appetite "
which requires "tempting," it is his digestion which requires sparing.
And good sick cookery will save the digestion half its work.

There may be four different causes, any one of which will produce
the same result, viz., the patient slowly starving to death from want
of nutrition :

1. Defect in cookings

2. Defect in choice of diet ;■

3. Defect in choice of hours for taking diet;

4. Defect of appetite in patient.

Yet all these are generally comprehended in the one sweeping
assertion that the patient has " no appetite."

Surely many lives might be saved by drawing a closer distinction;
for the remedies are as diverse as the causes. The remedy for the
first is, to cook better ; for the second, to choose other articles of
diet ; for the third, to watch for the hours when the patient is in
want of food ; for ithe fourth, to show him what he likes, and some-
times unexpectedly. But no one of these remedies wiU do for any
other of the defects not corresponding with it.

I cannot too often repeat that patients are generally either too
languid to observe these things, or too shy to speak about them ; nor
is it well that they should be niade to observe them, it fixes their
attention upon themselves.

OBSEBVATION OF THE SICK. 63

Again, I say, what is the nurse or friend there for except to take
note of these things, instead of the patient doing so ?^'

Again, the question is sometimes put. Is there diarrhoea ? And As to diar-
the answer will be the same, whether it is just merging into cholera, rhoea.
whether it is a trifling degree brought on by some trifling indiscre-
tion, which will cease the moment the cause is removed, or whether
there is no diarrhoea at all, but simply relaxed bowels.

It is useless to multiply instances of this kind. As long as
observation is so little cultivated as it is now, I do believe that it is
better for the physician not to see the friends of the patient at all.
They will oftener mislead him than not. And as often by making
the patient out worse as better than he really is.

In the case of infants, everything must depend upon the accurate
observation of the nurse or mother who has to report. And how
seldom is this condition of accuracy fulfilled.

A celebrated man, though celebrated only for foolish things, has Means of
told us that one of his main objects in the education of his son, was cultivating
to give him a ready habit of accurate observation, a certainty of per- sound and
ception, and that for this purpose one of his means was a month's JP^^^ ob.serva-
course as follows r — he took the boy rapidly past a toy-shop ; the
father and son then described to each other as many of the objects as
they could, which they had seen in passing the windows, noting them
down with pencil and paper, and returning afterwards to verify their
own accuracy. The boy always succeeded best, e.g., if the father
described 30 objects, the boy did 40, and scarcely ever made a
mistake,

I have often thought how wise a piece of education this would be
for much higher objects ; and in our calling of nurses the thing itself
is essential. For it may sately be said, not that the habit of ready
and correct observation will by itself make us useful nurses, but that
without it we shall be useless with all our devotion.

I have known a nurse in charge of a set of wards who not only
carried in her head all the little varieties in the diets which each
patient was allowed to fix for himself, but also exactly what each
patient had taken during each day. I have known another nurse in
charge of one single patient, who took away his meals day after day
iall but untouched, and never knew it.

If you find it helps you to note down such things on a bit of
paper, in pencil, by all means do so. I think it more often lames
than strengthens the memory and observation. But if you cannot
get the habit of observation one way or other, you had better give up
the being a nurse, for it is not your calling, however kind and
anxious you may be.

* It is commonly supposed that the nurse is there to spare the patient from More impor-
making physical exertion for himself— I would rather say that she ought to be there tant to spare
to spare him from taking thought for himself. And I am quite sure, that it the the patient
patient were spared all thought for himself, and not spared all physical exertion, thought thaa
he would be infinitely the gainer. The reverse is generally the case in the private physical excr-
house. In the hospital it is the relief trom all anxiety, aflorded by the rules of a tion.
well-regulated institution, Avhich has often such a beneficial eflect upon the
paiieut.

64

NOTES ON NURSING.

Surely you can learn at least to judge witK tlie eye how mucli an

oz. of solid food is, how much an oz. of liquid. You will find this

helps your observation and memory very much, you will then say to

yourself " A. took about an oz. of his meat to day;" " B. took three

times in 24 hours about ^ pint of beef tea;" instead of saying " B.

has taken nothing all day," or " I gave A. his dinner as usual."

Sound and I have known several of our real old-fashioned hospital " sisters,"

ready observa- who could, as accurately as a measuring glass, measure out all their

tion essential patients' wine and medicine by the eye, and never be wrong. I do

lu a nurse. ^^^^ recommend this, one must be very sure of one's self to do it. 1

only mention it, because if a nurse can by practice measure medicine

by the eye, surely she is no nurse who cannot measure by the eye

about how much food (in oz.) her patient has taken.* In hospitals

those who cut up the diets give with quite sufficient accuracy, to each

patient, his 12 oz. or his 6 oz. of meat without weighing. Yet a

nurse will often have patients loathing all food and incapable of any

will to get well, who just tumble over the contents of the plate or dip

the spoon in the cup to deceive the nurse, and she will take it away

without ever seeing that there is just the same quantity of food as

when she brought it, and she will tell the doctor, too, that the patient

English * It may be too broad an assertion, and it certainly sounds like a paradox,

women have But I think that in no country are women to be found so deficient in ready and
great capacity sound observation as in England., while peculiarly capable of being trained to it.
of but little The French or Irish woman is too quick of perception to be so sound an observer-
practice in the Teuton is too slow to be so ready an observer as the English woman might
close observa- be. Yet English women lay themselves open to the charge so often made against
tion. them by men, viz., that they are not to be trusted in handicrafts to which their
Btrength is quite equal, for want of a practised and steady observation. In
countries where women (with average intelligence certainly not superior to that oi
Englivih women ^ are employed, e. g., in dispensing, men responsible for what these
women do (not theorizing about man's and woman's "missions"), havestated that
they preferred the service of women to that of men, as being morii exact, more
careful, and incurring fewer mistakes of inadvertence.

Now certainly Englishwomen are peculiarly capable of attaining to this.
I remember when a child, hearing the story of an accident, related by some
one who sent two girls to fetch a "bottle of salvolatile from her lOom:" "Mary
..•ould not stir," she said, " Fanny ran and fetched a bottle that was not jsalvolatile,
iiud that was not in my room."

Now this sort of thing pursues every one through life. A woman is asked
to fetch a large new bound red book, lying on the table by the window, and
the fetches five small old boarded brown books lying on the shelf bj- the fire.
And this, though she has " put that room to rigats " every day for a month
perhaps, and must have observed the books every day, lying in the same p-accz.,
for a month, if she had any observation.

Habitual observation is the morp necessary, when any sudden call arises. If
"Fanny " had observed ''the bottle of salvolatile " in " the aunt's room," every
day she was there, she would more probably have found it when it was suddenly
wanted.

There are two causes for these mistakes of inadvertence. 1. A want of ready
attention: only part of the request is he»ud at all. 2. A want of the habit of
observation.

To a nurse I would add, take care that you always put the same things in the
same places ; you don't knew how suddenly you may be called on some day to
find something, and may not be able to remember in your haste where you your-
self had put it, ii your memory is not in thehabit of seeing the thiu^ there always.

OBSEEYATION OP THE SICK. Q5

has eaten all his diets as usual, when all she ought to have meant is
that she has taken away his diets as usual.
Now what kind of a nurse is this ?

I would call attention to something else, in which nurses fre- DifToronce of
quently fail in observation. There is a well-marked distinction excitable ami
between tlie excitable and what I will call the accumulative tempera- ^^^^^^if^^''"^
ment in patients. One will blaze up at once, under any shock or i^^^u^a.
anxiety, and sleep very comfortably after it ; another will seem quite
calm and even torpid, under the same shock, and people say, " He
hardly felt it at all," yet you will find him some time after slowly
sinking. The same remark applies to the action of narcotics, of ape-
rients, which, in the one, take eftect directly, in tlie other not
perhaps for twenty-four hours. A journey, a visit, an unwonted
exertion, will affect the one immediately, but he recovers after it ; the
other bears it very well at the time, apparently, and dies or is pros-
trated for life by it. People often say how difficult the excitable
temperament is to manage. I say how difficult is the accumulative
temperament. With the first you have an out-break which you could
anticipate, and it is all over. With the second you never know where
you are — you never know when the consequences are over. And it
requires your closest observation to know what «re the consequences
of what— for the consequent by no means follows immediately upon
the antecedent — and coarse observation is utterly at fault.

Almost all superstitions are owing to bad observation, to the post Superstition
Tioc, ergo propter hoc ; and bad observers are almost all superstitious, the tmit of
Farmers used to attribute disease among cattle to witchcraft; wed- J^^'^^^^®^^^*
dings have been attributed to seeing one magpie, deaths to seeing
three ; and I have heard the most highly educated now-a-days draw
consequences for the sick closely resembling these.

Another remark : although there is unquestionably a physi- physio^-
ognomy of disease as well as of health ; of all parts of the body, the nomv of disease
face is perhaps the one which tells the least to the common observer I'S^tle si.e»vii
or the casual visitor. Because, of all parts of the body, it is ^^^ ^^^ ^^-
the one most exposed to other influences, besides health. And
people never, or scarcely ever, observe enough to know how to dis-
tinguish between the effect of exposure, of robust health, of a tender
skin, of a tendency to congestion, of suffusion, flushing, or many
other things. Again, the face is often the last to shew emaciation.
I should say that the hand was a much surer test than the face, both
as to flesh, colour, circulation, &c., &c. It is true that there are
some diseases which are only betrayed at all by something in the
face, e.g., the eye or the tongue, as great irritability of brain by
the appearance of the pupil of the eye. But we are talkino; of casual,
not minute, observation. And few minute observers will hesitate
to say that far more untruth than truth is conveyed by the oft
repeated words. He looks well, or ill, or better or worse.

Wonderful is the way in which people will go upon the slightest
observation, or often upon no observation at all, or upon some saw
which the world's experience, if it had any, would have pronounced
utterly false long ago.

F

66

NOTES ON NUESING.

Peculiaritica
of patients.

T^urse must
o1 serve for
herself in-
crease of
patient's weab
ness, patient
will not tell
her.

I have known patients dying of slieer pain, exhaustion, and wanfc
of sleep, fj-oin one, of the most lingering and painful diseases known,
preserve, till within a few days of death, not only tlie healthy colour
of the clieek, but the mottled appearance uf a robust child. And
scores of times have I heard these unfortunate creatures assaded w4th,
" I am glad to see you looking so well." " I see no reason why you
should not live till ninety years of age." " AVhy don't you take a
little more exercise and amusement ?" with all the other common-
places with which we are so familiar.

There is, unquestionably, a physiognomy of disease. Let the
nurse learn it.

The experienced nurse can always tell that a person has taken a
narcotic the night before by the patchiness of the colour about the
face, when the re-action of depression has set in ; that very colour
which the inexperienced will point to as a proof of health.

There is, again, a fiiintness, which does not betray itself by the
colour at all, or in which the patient becomes brown instead of w^hite.
There is a faintness of another kind which, it is true, can always be
seen by the paleness.

But the nurse seldom distinguishes. She will talk to the patient
who is too faint to move, without the least scruple, unless he is pale
and unless, luckily for him, the muscles of the throat are affected and
he loses his voice.

Yet these two faintnesses are perfectly distinguishable, by the
mere countenance of the patient.

Again, the nurse must distinguish between the idiosyncracies of
patients. One likes to suffer out all his suffering alone, to be as little
looked after as possible. Another likes to be perpetually made much
of and pitied, and to have some one always by him. Both these
peculiarities might be observed and indulged much more than they
are. For quite as often does it happen that a busy attendance is
forced upon the first patient, who wishes for nothing but to be "let
alone," as that the second is left to think himself neglected.

Again, I think that few things press so heavdy on one suffering
from long and incurable illness, as the necessity of recording in
words from time to time, for the information of the nurse, who will
' not otherwise see, that he cannot do this or that, which he could do
a month or a year ago. What is a nurse there for if she cannot
observe these things for herself? Yet I have known — and known
too among those — and chief 1/ among those — whom money and
position put in possession of everything which money and position
could give — I have known, I say, more accidents, (fatal, slowly or
iQpidly,) arising from this want of observation among nurses than
from almost anything else. Because a patient could get out of a
warm-bath alone a month ago — because a patient could walk as far
as his bell a week ago, the nurse concludes that he can do so now^
{She has never observed the change ; and the patient is lost from
being left in a helpless state of exhaustion, till some one accidentally
conieb in. And this not from any unexpected apoplectic, paralytic,
or fainting fit (though even these could be expected far more, at

OESEEYATION OF THE SICK. 67

least, than they are now, if we did but observe). No, from the
expected, or to be expected, inevitable, visible, calculable, uninter-
rupted increase of weakness, which none need tail to observe.

Again, a patient not usually confined to bed, is compelled by an Accidents
attack of diarrhoea, vomiting, or other accident, to keep his bed for a arising trom
few days ; he gets up for the first time, and the nurse lets him go ^'^<^ nurse's
into, another room, without coming in, a few minutes afterwards, to ^^^^J^^ ^ '^*
look after him. It never occurs to her that he is quite certain to be
faint, or cold, or to want something. She says, as her excuse,
Oh, he does not like to be fidgetted after. Yes, he said so some
weeks ago ; but he never said he did not like to be " fidgetted after,"
when he is in the state he is in now ; and if he did, you ought to
make some excuse to go in to him. More patients have been lost in
this way than is at all generally known, viz., from relapses brought
on by being left for an hour or two faint, or cold, or hungry, after
getting up for the first time.

Yet it appears that scarcely any improvement in the faculty Is the faculty
of observing is being made. Vast has been the increase of know- of observing
ledge in pathology — that science which teaches us the final change ^^^^*^'^^*^'^^^-
produced by disease on the human frame — scarce any in the art of
observing the signs of the change while in progress. Or, rather, is
It not to be feared that observation, as an essential part of medicine,
has been declining ?

AVhich of us has not heard fifty times, from one or another, a
nurse, or a friend of the sick, aye, and a medical friend too, the
following remark : — " So A is worse, or B is dead. I saw him
the day before ; I thought him so much better ; there certainly
was no appearance from which one could have expected so
sudden (?) a change." I have never heard any one say, though
one would think it the more natural thing, " There must have
been some appearance, which I should have seen if I had but
looked ; let me try and remember what there was, that I may observe
another time." No, this is not what people say. They boldly
assert that there was nothing to observe, not that their observation
was at fault.

Let people who have to observe sickness and death look back and
try to register in their observation the appearances which have
preceded relapse, attack, or death, and not assert that there were
none, or that there were not the right ones.*

A want of the liabit of observing conditions and an inveterate Observation
habit of taking averages are each of them often equally misleading. Iq^I\1\q^,^

* It falls to few ever to have had the opportunity of observing the different Approach o
aspects which tne human face puts on at the sudden approach of certain forms of death palcncs8
death by violence ; and as it is a knowledge of little use I only mention it here by no means
as being the most startling example of what I mean. In the nervous tcm- an invariable
pcrament the face becomes pale (this is the only recognized efiect); in the eilect, as we
sanguine temperament purple; in the bilious yellow, or every manner of colour find in novels,
in patches. jS"ow, it is generally supposed that paleness is the one indication
of almost, any violent change in the human being, whether from terror, disease,
or anything else. There can be no more false observation. Granted, it is the
one recognized livery, as I have said -de rigueur in novels, but nowhere else.

r 2

68 NOTES ON NUESING.

Men wliose profession like that of medical men leads them to
observe only, or chiefly, palpable and permanent organic changes are
often just as wrong in their opinion of the result as those who do
not observe at all. For instance, there is a broken leg ; the surgeon
has only to look at it once to know ; it will not be different if he
sees it in the morning to what it would have been had he seen
it in the evening. And in whatever conditions the patient is, or is
likely to be, there vrill still be the broken leg, until it is set. The
same with many organic diseases. An experienced physician has
but to feel the pulse once, and he knows that there is aneurism
which will kill some time or other.

But with the great m;ijority of cases, there is nothing of the kind ;
and the power of forming any correct opinion as to the result must
entirely depend upon an enquiry into all the conditions in which the
patient lives. In a complicated state of society in large towns,
death, as every one of great experience knows, is far less often pro-
duced by any one organic disease than by some illness, after many other
diseases, producing just the sum of exhaustion necessary for death.
There is nothing so absurd, nothing so misleading as the verdict one
so often bears : So-and-so has no organic disease, — there is no reason
M'hy he should not live to extreme old age ; sometimes the clause
is added, sometimes not : Provided he has quiet, good food, good air,
&c., &c,, &c. ; the verdict is repeated by ignorant people witliout the
latter clause ; or there is no possibility of the conditions of the
latter clause being obtained ; and this, the only essential part of the
whole, is made of no effect. I have heard a physician, deservedly
eminent, assure the friends of a patient of his recovery. Why ?
Because he had now prescribed a course, every detail of which the
patient had followed for years. And because he had forbidden a
course which the patient could not by any possibility alter.*

* I have known two cases, the one of a man who intentionally and repeatedly
displaced a dislocation, and was kept and petted by all the surgeons, the other
of one who was pronounced to have nothing the matter with him, there being
no organic change perceptible, but who died within the week. In both these
cases, it was the nurse who, by accurately pointing out what she had accurately
observed, to the doctors, saved the one case from persevering in a fraud, the other
from being discharged when actually in a dying state.

I will even go further and say, that in diseases which have their origin in the
feeble or irregular action of some function, and not in organic change, it is quite
an accident if the doctor who sees the case only once a day, and generally at the
game time, can form any but a negative idea of its real condition. In the middle
of the day, when such a patient has been refreshed by light and air, by his tea,
his beef tea, and his brandy, by hot bottles to his feet, by being washed and by
clean linen, you can scarcely believe that he is the same person as lay with a rapid
fluttering pulse, with puffed eye-lids, with short breath, cold limbs, and unsteady
hands, this morning. Now what is a nurse to do in such a case ] Not crj', " Lord
bless you, sir, why you"d have thought he were a dying all night." This may be
true, but it is not the way to impress with the truth a doctor, more capable of form-
ing a judgment from the facts, if he did but knoAv them, than you are. What he
wants is not your opinion, however respectfully given, but your facts. In all
diseases it is important, but in diseases which do not run a distinct and fixed
course, it is not only important, it is essential that the facts the nur.<e alone can
observe, should be accurately observed, and accurately reported to the doctor.

OBSERVATION OF THE SICK. b\)

Undoubtedly a person of no scientific knowled^^e whatever but of
observation and experience in these kinds of conditions, will be able
to arrive at a much truer guess as to the probable duration of life of
members of a family or inmates of a house, than the most scientific
physician to whom the same persons are brought to have their pulse
felt; no enquiry being made into their conditions.

In Life Insurance and such like societies, were they instead of
having the personsuexamined by a medical man, to have the houses,
conditions, ways of life, of these persons examined, at how much
truer results would they arrive ! W. Siinth appears a fine hale man,
but it might be known that the next cholera epidemic he runs a bad
chance. Mr. and Mrs. J. are a strong healthy couple, but it might
be known that they live in such a bouse, in such a part of London,
so near the river that they will kill four-fifths of their children ;
which of the children will be the ones to survive might also be
known.

Averages again seduce us away from minute observation. Avera.^es
"Average mortalities " merely tell that so many percent, die in this of mortali'y
town and so many in that, per annum. But whether A or B will be J^l^t ^o^^"jJ^.
among these, the " average rate " of course does not tell. We know, ^^^^ ^^-iil
say, that from 22 to 24 per 1,000 will die in London next year. But die. Observa-
minute enquiries into conditions enable us to know that in such a tion must tell
district, nay, in such a street, — or even on one gide of that street, in us?i7/?ic/i in the
such a particular house, or even on one floor of that particular ^.VjJ /^ ^^'^^

I must direct the nurse'g attention to the extreme variation there is not unfre- ^^ ^ '
qnently in the pulse of such patients during the day. A very common case is
this: Between 3 and 4 a.m. the pulse becomes quick, perhaps 130, and so
thready it is not like a pulse at all, but like a string vibrating just underneath
the skin. After this the patient gets no more sleep. About mid-day the pulse
has come down to 80 ; and though feeble and compressible is a very respectable
pulse. At night, if the patient has had a day of excitement, it is almost imper-
ceptible. But, if the patient has had a good day, it is stronger and steadier and
not quicker than at midday. This is a common history of a common pulse;
and others, equally varying during the day, might be given. Now, in inflamma-
tion, which may almost always be detected by the pulse, in typhoid fever, which
is accompanied by the low pulse that nothing will raise, there is no such great
variation. And doctors and nurses become accustomed not to look for it. The
doctor indeed cannot, Eut the variation is in itself an important feature.

Cases like the above often "go off rather suddenly," as it is called, from some
trifling ailment of a few days, which just makes up the sum of exhaustion neces-
sary to produce death. And everybody cries, who would have thought it? except
the observing nurse, if there is one, who had always expected the exhaustion to
come, from which tliere would be no rally, because she knew the patient had no
capital in sti ength on which to draw, if he failed for a few days to make his
barely daily income in sleep and nutrition.

I have often seen really good nurses distressed, because they could not impress
the doctor with the real danger of their patient; and quite provoked because
the patient "would look," either "so much better" or "so much worse" than
he really is "when the doctor was there." The distress is very legitimate,
but it generally arises from the nurse not having the power of laying clearly and
shortly before the doctor the facts from whirh slie derives her opinion, or from
the doctor being hasty and inexperienced, and not capable of eliciting them. A
man who really cares for his patients, will soon learn to ask for and appreciate the
information of a nui-se, who is at once a careful observer and a clear reporter.

70 NOTES ON KURSIIfG.

liouse, will be the excess of mortality, that is, the person will die
who ought not to have died before old age.

Now, would it not very materially alter the opinion of whoever
were endeavouring to form one, if he knew that from that fioor, of
that house, of that street the man came?

Much more precise might be our observations even than this and
much more correct our conclusions.

It is well known that the same names may be seen constantly
recurring on workhouse books for generations. That is, the persona
were born and brought up, and will be born and brought up, genera-
tion after generation, in the conditions which make paupers. Death
and disease are like the workhouse, they take from the same family,
the same house, or in other words the same conditions. Why will
we not observe what they are ?

The close observer may safely predict that such a family, whether
its members marry or not, will become extinct ; that such another
will degenerate morally and physically. But who learns the lesson ?
On the contrary, it may be well known that the children die in such
a house at the rat-e of 8 out of 10 ; one would think that nothing
more need be said ; for how could Providence speak more distinctly ?
yet nobody listens, the family goes on living there till it dies out,
and then some other family takes it. Neither would they listen " if
one rose from the dead."
What observa- In dwelling upon the vital importance of sound observation, it
tiou is (or. must never be lost sight of what observation is for. It is not for the
sake of piling up miscellaneous information or curious facts, but for
the sake of saving life and increasing health and comfort. The
caution may seem useless, but it is quite surprising how many
men (some women do it too), practically behave as if the scientific
end were the only one in view, or as if the sick body were but a
reservoir for stowing medicines into, and the surgical disease
only a curious case the sufferer has made for the attendant's
special information. This is really no exaggeration. Ton think,
if you suspected your patient was being poisoned, say, by a copper
kettle, you would instantly, as you ought, cut oif all possible
connection between him and the suspected source of injury, with-
out regard to the fact that a curious mine of observation is
thereby lost. But it is not everybody who does so, and it has
actually been made a question of medical ethics, what should the
medical man do if he suspected poisoning ? The answer seems a very
simple one, — insist on a confidential nurse being placed with the
patient, or give up the case.
What a con- And remember every nurse should be one who is to be

'/^^"m ^"^^^ ^^P^^ded upon, in other* words, capable of being a " confidential "
lou c, nurse. She does not know how soon she may find herself placed
in such a situation ; she must be no gossip, no vain talker ; she
should never answer questions about her sick except to those who
have a right to ask them ; she must, I need not say, be strictly
sober and honest ; but more than this, she must be a religious
and devoted woman ; she must have a respect for her own calling,

CONCLUSION. 71

because God's precious f^ift of life is often literally placed in lier
hands; she must be a sound, and close, and quick observer; and slie
must be a woman of delicate and decent feeling.

To return to the question of what observation is for : — It would Obserfation ii
really seem as if some had considered it as its own end, as if detec- for practical
tion, not cure, was their business ; nay more, in a recent celebrated purposes,
trial, three medical men, according to their own account, suspected
poison, prescribed for dysentery, and left the patient to the poisoner.
This is an extreme case. But in a small way, the same manner of
acting falls under the cognizance of us all. How often the attendants
of a case have stated that they knew perfectly well that the patient
could not get well in such an air, in such a room, or under such
circumstances, yet have gone on dosing him with medicine, and
making no effort to remove the poison from him, or him from the
poison which they knew was killing him ; nay, more, have some-
times not so much as mentioned their conviction in the right quarter
— that is, to the only person who could act in the matter.

CONCLUSION.

The whole of the preceding remarks apply even more to children Sanitary
and to puerperal women than to patieiits in general. They also nursing as

apply to the nursing of surgical, quite as much as to that of medical ^^^^^'^^^^ ^".

^r^ J , & to 5 1 ,. , 1 • • • ! surgical as in

cases. Indeed, it it be possible, cases ot external injury require such medical cases
care even more than sick. In surgical wards, one duty of every nurse but not to sn-
certainly is iwevention. Fever, or hospital gangrene, or pyoemia, or persede surgi-
purulent discharge ot some kind may else supervene. Has she a case cal nursing,
of compound fracture, of amputation, or of erysipelas, it may depend
very much on how she looks upon the things enumerated in these
notes, whether one or other of these hospital diseases attacks her
patient or not. If she allows her ward to become filled with the
peculiar close foetid smell, so apt to be produced among surgical
cases, especially where there is great suppuration and discharge, she
may see a vigorous patient in the prime of life gradually sink and die
where, according to all human probability, he ought to have recovered.
The surgical nurse must be ever on the watch, ever on her guard,
against want of cleanliness, foul air, want of light, and of warmth.

Nevertheless let no one think that because sanitary nursing is the
subject of these notes, therefore, what maj be called the handicraft of
nursing is to be undervalued. A patient may be left to bleed to death
in a sanitary palace. Another who cannot move himself may die of
bed-sores, because the nurse does not know how to change and
clean him, while he has every requisite of air, light, and quiet. But
nursing, as a han;licraft, has not been treated of here for three
reasons : 1. that these notes do not pretend to be a manual for
nursing, any more than for cooking for the sick ; 2. that the writer,
who has herself seen more of what may be called surgical nursing,
i.e, practical manual nursing, than, perhaps, any one in Europe,

72 TJ-OTES 0?T KTJBSI55-G.

honestly believes that it is impossible to learn it from any book, and
that it can only be thoroughly learnt in the wards of a hospital ; and
she also honestly believes that the perl'ection of surgical nursing may
be seen practised by the old-fashioned "Sister" of a London hospital,
as it can be seen nowhere else in Europe. 3. While thousands die
of foul air, &c., who have this surgical nursing to perfection, the
converse is comparatively rare.
Children : ^^ revert to children. They are much more susceptible than grown

their greater poople to all noxious influences. They are affected by the same
susceptibility things, but much more quickly and seriously, viz., by want of fresh
to the same air, of proper warmth, want of cleanliness in house, clothes, bedding,
things. Qj, body, by startling noises, improper food, or want of punctuality,

by dulness and by want of light, by too much or too little covering
in bed, or when up, by want of the spirit of management generally
in those in charge of them. One can, therefore, only press the im-
portance, as being yet greater in the case of children, greatest in the
case of sick children, of attending to these things.

That which, however, above all, is known to injure children
seriously is foul air, and most seriously at night. Keeping the rooms
where they sleep tight shut up, is destruction to them. And, if the
child's breathing be disordered by disease, a few hours only of such
foul air may endanger its life, even where no inconvenience is felt
by grown-up persons in the same room.

The following passages, taken out of an excellent " Lecture on
Sudden Death in Infancy and Childhood," just published, show the
vital importance of careful nursing of children. " In the great
majority of instances, when death suddenly befalls the infant or young
child, it is an accident; it is not a necessary, inevitable result of any
disease from which it is suffering."

It may be here added, that it would be very desirable to know
how often death is, with adults, " not a necessary, inevitable result
of any disease." Omit the word " sudden ;" (for sudden death is
comparatively rare in middle age ;) and the sentence is almost equally
true for all ages.

The following causes of " accidental" death in sick children are
enumerated : — " Sudden noises, which startle — a rapid change of
temperature, which chills the surface, though only for a moment
— a rude awakening from sleep — or even an over-hasty, or an over-
full meal" — " any sudden impression on the nervous system — any
hasty alteration of posture — in short, any cause whatever by which
the respiratory process may be disturbed."

It may agnin be added, that, with very weak adult patients, the^ie
causes are also (not often '' suddenly fatal," it is true, but) very much
oftener than is at all generally known, irreparable in their con-
sequences.

Both for children and for adults, both for sick and for well
(although more certainly in the case of sick children than in any
others), I would here again repeat, the most frequent and most
fatal cause of all is sleeping, tor even a few hours, nnich more for
weeks and months, in foul air, a condition which, more than any

COKCLTJSIOH". 73

other condition^ disturbs tlie respiratory process, and tends to pro-
duce " accidental" death in disease.

I need hardly here repeat the warning against any confusion of
ideas between cold and fresh air. You may chill a patient fatally
without giving him fresh air at all. And you can quite well, nay,
much better, give him fresh air without chilling him. This is the
test of a good nurse.

In cases of long recurring faintnesses from disease, for instance,
especially disease which affects the organs of breathing, fresh air to
the lungs, warmth to the surface, and often (as soon as the patient
can swallow) hot drink, these are the right remedies and the only
ones. Yet, oftener than not, you see the nurse or mother jusfc
reversing this ; shutting up every cranny through which fresh air can
enter, and leaving the body cold, or perhaps throwing a greater
weight of clothes upon it, when already it is generating too little heat.

" Breathing carefully, anxiously, as though respiration were a
function which required all the attention for its performance," is
cited as a not unusual state in children, and as one calling for care
in all the things enumerated above. That breathing becomes an
almost voluntary act, even in grown up patients who are very
fveak, must often have been remarked.

" Disease having interfered with the perfect accomplishment of
the respiratory function, some sudden demand for its complete exer-
cise, issues in the sudden stand still of the whole machinery," is given
as one process: — " life goes out for want of nervous power to keep
the vital functions in activity," is given as another, by which "acci-
dental" death is most often brought to pass in infancy.

Also in middle age, both these processes may be seen ending in
death, although generally not suddenly. And I have seen, even in
middle age, the ^^ sudden stand-still" here mentioned, and from the
same causes.

To sum up : — the answer to two of the commonest objections Summary,
urged, one by women themselves, the other by men, against tne
desirableness of sanitary knowledge for women, plus a caution,
comprises the whole argument for the art of nursing.

(1.) It is often said by men, that it is unwise to teach women Reckless ama-
anything about these laws of health, because they will take to I'®"'' pliy^ick-
physicking, — that there is a great deal too much of amateur physick- i?f i ^now^^^'
ing " it is, which is indeed true. One eminent physician told me ledo-e of the
that ne had known more calomel given, both at a pinch and for a laws of health
continuance, by mothers, governesses, and nurses, to children than alone can
he had ever heard of a physician prescribing in all his experience, check this.
Another says, that women's only idea in medicine is calomel and
aperients. This is undeniably too often the case. There is nothing
ever seen in any professional practice like the reckless physicking by
amateur females.* But this is just what the really experienced and

* I have known many ladies who, having once obtained a "blue pill" prcscrip- Darigcr of f hy-
tion from a physician, gave and took it as a common aperient two or thi-^e tinr^i< sicking by
a week — with what effect may be supposed. In one case I happened to Ve tV<» amateur
person to ioform the physician of it, who substituted for the prescription a com- temalcs.

logy teaches
What obser-
vation alone

74 NOTES ON NUESING.

observing nurse does not do ; she neither physics herself nor others.
And to cultivate in things pertaining to health observation and expe-
rience in women who are mothers, governesses or nurses, is just the
way to do away with amateur physicking, and if the doctors did but
know it, to make the nurses obedient to them, — helps to them
instead of hindrances. Such education in women would indeed
diminish the doctor's work — but no one really believes that
doctors wish that there should be more illness, in order to have more
work.
What patho- (2.) It ip ot'i.^n said by women, that they cannot know anything of

the laws of he:iith, or what to do to preserve their children's health,
because they can know nothing of " Pathology," or cannot " dissect,"
teaches What — ^ coufu.'sion of iddiis which it is hard to attempt to disentangle,
medicine does. Pathology teaches the harm that disease has done. But it teaches
What nature nothing more. We know nothing of the principle of health, the
alone does. positive of which pathology is the negative, except from observation
and experience. And nothing but observation and experience will
teach us the ways to maintain or to bring back the state of health.
It is often thought that medicine is the curative process. It is no such
thing ; medicine is the surgery of functions, as surgery proper is that
of limbs and organs. Neither can do anything but remove obstruc-
tions ; neither can cure ; nature alone cures. Surgery removes the

paratively harmless aperient pill. The lady came to me and complained that it
"did not suit her half so well."

If women will take or give physic^ by far the safest plan is to send for "the
doctor" every time— for I have known ladies who both gave and took physic,
who would not take the pains to learn the names of the commonest medicines,
and confounded, e. g., colocynth with coichicum. This is playing with sharp
edged tools " with a vengeance."

There are excellent women who will write to London to their physician that
there is much sickness in their neighbourhood in the country, and ask for some
prescription from him, which they used to like themselves, and then give it to all
their friends and to all their poorer neighbours who will take it. Xow, instead
of giving medicine, of which you cannot possibly know the exact and proper ap-
plication, nor all its consequences, would it not be better if you were to persuade
and help your poorer ne ghbours to remove the dung-hill from before the door, to
put in a window which opens, or an Arnott's ventila'or, or to cleanse and lime-wash
the cottages ] Of these things the benefits are sure. The benefits of the inexpe-
rienced administration of medicines are by no means so sure.

Homoeopathy has introduced one essential amelioration in the practice of
physic by amateur females ; for its rules are excellent, its physicking compara-
tively harmless— the "globule " is the one grain of folly which appears to be neces-
sary to make any good thing acceptable. Let then women, if they will give medi-
cine, give homoeopathic medicine. It won't do any harm.

An almost universal error among women is the supposition that everybody
must have the bowels opened once in every twenty-four hours or must fly imme-
diately to aperients. The reverse is the conclusion of experience.

This is a doctors subject, and I will not enter more into it; but will simply
repeat, do not go on taking or giving to your children your abominable " courses of
aperients," without calling in the doctor.

It is very seldom indeed, that by choosing your diet, you cannot regulate
\our OM'n bowels; and every woman may watch herself to know what kind of
diet will do this; I have known deficiency of meat produce constipation, quite as
often as deficiency of vegetables ; baker's bread much oftener than either. Home
made brown bread will ofteuer cure it than anything else.

CONCLUSION. 75

bullet out of the limb, "u-hich is an obstruction to cure, but nature
heals the wound. So it is with medicine; the function of an organ
becomes obstructed ; medicine, so far as we know, assists nature !o
remove the obstruction, but does nothing more. And what nursing
has to do in either case, is to put the patient in the best condition
for nature to act upon him. Generally, just the contrary is done.
You think fresh air, and quiet and cleanliness extravagant, perhaps
dangerous, luxuries, which should be given to the patient only when
quite convenient, and medicine the sine qua non, the panacea. If I
have succeeded in any measure in dispelling this illusion, and in
showing what true nursing is, and what it is not, my object will ha\e
been answered.

Now for the caution : —

(3.) It seems a commonly received idea among men and even
among women themselves that it requires nothing but a disappoint-
ment in love, the want of an object, a general disgust, or incapacity
for other things, to turn a woman into a good nurse.

This reminds one of the parish where a stupid old man was set
to be schoolmaster because he was " past keeping the pigs."

Apply the above receipt for making a good nurse to making a
good servant. And the receipt will be found to fail.

Yet popular novelists of recent days have invented ladies dis'ip-
pointed in love or fresh out of the drawing-room turning into the
war-hospitals to find their wounded lovers, and when found, forthwith
abandoning their sick-w^ard for their lover, as might be expected. Yet
in the estimation of the authors, these ladies were none the worse
for that, but on the contrary were heroines of nursing.

What cruel mistakes are sometimes made by benevolent men and
women in matters of business about which they can know nothing
and think they know a great deal.

The everyday management of a large ward, let alone of a hospital
— the knowing what are the laws of life and death for men, and
what the laws of health for wards — (and wards are healthy or un-
healthy, mainly according to the knowledge or ignorance of the
nurse) — are not these matters of sufficient importance and difficulty
to require learning by experience and careful inquiry, just as much as
any other art ? They do not come by inspiration to the lady disap-
pointed in love, nor to the poor workhouse drudge hard up for a
livelihood.

And terrible is the injury which has followed to the sick from
such wild notions !

In this respect (and wby is it so ?), in Eoman Catholic countries,
both writers and workers are, in theory at least, far before ours.
They would never think of such a beginning for a good working
Superior or Sister of Charity. And many a Superior has refused to
admit a Fostidant who appeared to have no better "vocation" or
reasons for offering herself than these.

It is true ive make "no vows." But is a "vow" necessary to
convince us that the true spirit for learning any art, most especially
an art of charity, aright, is not a disgust to everything or {something

76 NOTES ON KURSING.

e]ce ? Do we really place the love of our kind (and of nursing, as
<5ne branch of it.) so low as this ? What would the Mere Angeiique
of Port E-oyal, what would our own Mrs. Fry have said to this ?

Note. — I would earnestly ask my sisters to keep clear of both the jargons
now current everywhere (for they are equally jargons) ; of the jargon, namely,
about the "rights" of women, which urges women to do all that m^en do, including
the medical and other professions, merely because men do it, and without regard
to whether this is the best that women can do ; and of the jargon which urges
women to do nothing that men do, merely because they are women, and should be
"recalled to a sense of their duty as women," and because "this is women's work,"
and " that is men's," and " these are things which women should not do," which is
all asserti-on and nothing more. Surely woman should bring the best she has,
whatever that is, to the work of God's world, without attending to either of these
cries. For what are they, both of them, the one jiuit as much as tbe other, but
listening to the "what people will say," to opinion, to the "voices from without?"
And as a wise man has said, no one has ever done anything great or useful by
listening to the voices from without.

You do not want the effect of your good things to be, " How wonderful for a
woman!'' nor would you be deterred from good things, by hearing it said, "Yes,
but she ought not to have done this, because it is not suitable for a woman." But
you want to do the thing that is good, whether it is " suitable for a woman "
or not.

It does not make a thing good, that it is remarkable that a woman should
have been able to do it. Neither does it make a thing bad, which would have
been good had a man done it, that it has been done by a woman.

Oh, leave these jargons, and go your way straight to God's vrork, in simplicity
and singleness of heart.

APPENDIX.

78

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KOTE. 79

Note as to the Numbee of Wome?^ employed as

NUIISES IN GrEEAT BeITAIN.

25,466 were returned, at the census of 1S51, as nurses by pro-
fession, 39,139 nurses in domestic service,* and 2,822 midwives.
The numbers of different ages are shown in table A, and in table B
their distribution over Grreat Britain.

To increase the efficiency of this class, and to make as many of
them as possible the disciples of the true doctrines of health, would
be a great national work.

For there the material exists, and will be used for nursing,
whether the real " conclusion of the matter" be to nurse or to poison
the sick. A man, who stands perhaps at the head of our medical
profession, once said to me, I send a nurse into a private family to
nurse the sick, but I know that it is only to do them harm.

Now a nurse means any person in charge of the personal health
of another. And, in the preceding notes, the term muse is used
indiscriminately for amateur and professional nurses. For, besides
nurses of the sick and nurses of children, the numbers of whom are
here given, there are friends or relations who take temporary charge
of a sick person, there are mothers of families. It appears as if
these unprofessional nurses were just as miicii ii\ want of knowledge
of the laws of health as professional onea.

Then there are the school-mistresses of all national and other
schools throughout the kingdom. How many of children's epidemics
originate in these ! Then the proportion of girls in these schools,
who become mothers or members among the 64,600 nurses recorded
above, or schoolmistresses in their turn. If the laws of health, as
far as regards fresh air, cleanliness, light, &c., were taught to these,
would this not prevent some children being killed, some evil being
perpetuated ? On women we must depend, first and last, for personal
and household hygiene — for preventing the race from degenerating
in as far as these things are concerned. Would not the true way of
infusing the art of preserving its own health into the human race be
to teach the female part of it in schools and hospitals, both by
practical teaching and by simple experiments, in as iar as these illus-
trate what may be called the theory of it ?

* A curious fact will be shown by Table A, viz., that 18,122 out of 39,139, or
nearly one-half oi all the nurses, in domestic service, are between 5 and 20 ye^s
of age.

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